leftovers for neuro final

LOC* Loss of Consciousness mod TBI

30min -24 hrs

•Only __% of SCI are nontraumatic

38%

•Normal chest expansion

2.5 to 3 inches at xiphoid process

Hip UMN syndrome:

Add (sissc), IR, ext glutemax

MG Class I:

Any eye mm weakness, possible ptosis

JCAHO:

Joint commission on accreditation of healthcare organizations

Why is rehab similar to CVA and TBI?

Just like tumor in different parts of brain, can have stroke in different part of brain

_____ is considered the cardinal sign of ALS

Muscle weakness *Typically the weakness starts unilaterally, focal and asymmetrical.

T1-5

I: Intercostals, serratus E: Intercostals

Sensory Stimulation*** (severe TBI—Rancho II/III): Auditory stimulation

Only one person speaking at a time verbal communication: call person's name familiar songs and music listen to TV clapping your hands ring a bell whistle

Balance quantification:

SOT, Fukada

Hinged:

a posterior stop can be added to limit plantarflexion while a spring assist can be added to assist in DF

*somebody explain why an abdominal binder is good

a.Acutely. (blood pressure maintenance) b.Chronically (bolster abdominal muscles to allow diaphragm to sit appropriately, making inspiration and expiration more passive)

If home not accessible and no one to care for them, (CVA)

almost like a death sentence, probably go to SNF

common sites of focal brain injury are the

anterior-inferior temporal lobes and prefrontal lobes

LIS mortality rates

are high (59%)

passive movement difficult (CVA)

brunstrom 3

indirect als

contractures

acute- Thrombus

formation

Remember first goal:

get pt off ventilator and keep them off. Don't overwork a fragile patient and force them to go back onto the ventilator

Skin considerations: acute

muscle or skin flaps, open wounds, muscle flaps, wound care. After autografting hold therapy 4-5 days.

tx: dysesthesias:

narcotic analgesics discouraged due to ineffectiveness and addiction. Use neurontin, lyrica (anticonvulants drugs)—off-label use

•Pts in coma have

no spontaneous eye opening No response to vigorous sensory stimulation

lacunar strokes: might be super small-

numbness FA, a little weakness L quad- v isolated small things

Phase 1. Initial Contact: Active mm=

quads, gluts

Balance Retraining: Typically exhibit: (CVA)

delayed, varied, or absent balance responses with impairments in latency, amplitude, and timing

Early stages - ALS

exercise appears to be very beneficial •With strengthening be careful of overuse fatigue - Prolonged loss of strength in weakened denervated muscles •Disuse atrophy is also a problem so it is important to keep these individuals active. - At times hard to distinguish

20% of individuals with MCA strokes

fail to regain any functional use of the UE

BWSTT •Greatest gains in

fast velocity group

General appearance will be a factor as

the arousal, attention, cognition will play a part in our interventions

Lysis:

the disintegration of a cell by rupture of the cell wall or membrane

Serial casting is considered a favorable adjunct to physical therapy treatment to

to gain range of motion in patients with traumatic brain injury, especially if completed in the acute phase

Pain: MS

trigeminal neuralgia, Lhermitte's Sign, spasticity-related, MS hug, dysesthesia

Hemiheight WC-

using legs to propel WC

•Secondary/Symptomatic Parkinsonism

results of other identifiable causes (virus, toxins, drugs, tumors, multi-infarcts, etc)

What are the 4 clinical features? PD

rigidity bradykinesia tremor postural instability

Medical Management CVA: Control

seizures and infections

•Emotional Changes MS

•15% increase in suicide in this population •Suicidal ideation 7.5x more common than general population •Mood swings, irritability •Pseudobulbar affect LOTS of stressors

Portable Telemetry

•5-electrode configuration •White to the upper right •Clouds over grass •Smoke over fire •Chocolate close to your heart

DBP

•50 < DBP < 100 mmHg

PD Follow-up:

•6 months usually, sometimes 1 year •Fall prediction tools are only shown to be valid for 6 months in this population. •Progressive disease process •Sometimes early if things change

Pneumonia SCI

•70+ %

SBP

•80 < SBP < 180 mmHg

MS Vision problems -

•80-85%

Weakness (paresis) is found in

•80-90% of all patients s/p stroke •Major factor in disability

MS Gait difficulties

•87%

Ex VS: Pulse Oximetry/SpO2:

•> 4% decrease- hard bc with CP pts will drop (suddently) and often its after ex- be aware and pause and take sp02 and monitor and give ... •< 88%- 90%

Examination CVA (3 general)

•A&O, ability to speak, follow commands, visual fields • Tone (MAS, Brunnstrom) •Coordination

Elements of the exam and outcome measures

•Arousal, attention, cognition •Cranial nerve integrity •Gait, locomotion, balance •Integumentary •Joint integrity/mobility •Motor function •Muscle performance •Pain •Posture •ROM •Reflex integrity •Self-Care and ADL •Sensory integrity •Work/leisure, reintegration

Encephalitis- 5 Pathological Syndromes: Parainfectious encephalomyelitis

•Associated with measles, mumps, and varicella

Diagnosis•Other tests: MS

•Blood work/lab testing •MRI of CNS •Lumbar puncture/CSF testing •Evoked potentials - electrical response in the brain, slowing caused by demyelination

Acute care- Bone Demineralization

•Bone mineral density loss: •greatest at calcaneus •followed by the femoral neck, and spine •Can lead to fracture, even with minor trauma •Prevention: WEIGHT-BEARING exercise

CV imp's •Parasympathetics:

•Bradycardia •Dilation of the peripheral vasculature below level of lesion •Result is orthostatic hypotension during early transitions

Medical Diagnosis: CT •Subacute phase:

•CT scans can identify cerebral infarction (within 3-5 days)

Autonomic dysfunction (Signs and Symptoms - AIDP)

•Cardiovascular signs (Sinus bradycardia**, hypertension, cardiac arrhythmias and postural hypotension) •Urinary retention •Constipation (bowel paresis and ↓ gastric motility) •Abnormal vasomotor tone •Sialorrhea •Anhidrosis [***Why would they have sinus bradycardia? CN's still intact- PS involvement like SCI- also not good return//other fxns -]

Below L1-2, the collection of long nerve roots is known as the

•Cauda Equina

•Impacts PD •Bradykinesia -

•Changes in flooring •Changing tasks •Cognitive load

PD •Rigidity - What does that look like?

•Cogwheel - catch and rel muiult times •Lead pipe- push v hard to try to bend •Both directions, regardless of speed, amplitude, task •Increased with active movement, concentration and emotional stress (cereuleospinal and raphespinal?) [Rigidity - felt uniformly in both directions of movement; constant regardless of task, amplitude, speed; proximal muscles first, asymmetric initially]

•Seizures CVA

•Common during the acute phase •Medications may have adverse side effects ( and ataxia)

•Cognitive Dysfunction CVA

•Confusion, perseveration, executive function, memory, attention, multi-infarct dementia

Musculoskeletal System acute

•Contractures •Atrophy-decreased muscle mass, strength (10-15%/week) and endurance •Altered electrical activity •Weakened myotendinous junction •Decreased strength of tendons and ligaments and bone insertions •Osteoporosis •Cartilage degeneration •Fibrofatty tissue infiltration (joint) •Synovial atrophy •Ankylosis •ANTIGRAVITY muscles

Other Secondary complications/Indirect impairments

•Contractures •Heterotopic ossification •Fracture/osteoporosis •Syringomyelia

stroke Major Risk Factors

•Diabetes Mellitus •↑ Hematocrit (↓ CBF) •Sleep apnea •Early menopause, first 6 weeks post partum, preeclampsia

Dysautonomia

•Diaphoresis •Hyperthermia •(Decerebrate and decorticate Posturing, teeth grinding, hypertonia) •"Paroxysmal sympathetic hyperactivity" the term used to describe these behaviors/signs/symptoms

•Bowel dysfunction Complications/Indirect Impairments CVA

•Diarrhea, constipation, impaction •Stool softeners, dietary/fluid modification, medication, Physical Activity

Differentiate stroke from acute vestibular syndrome: HINTS (Head Impulse Nystagmus Test of Skew)

•Direction Changing gaze-evoked nystagmus (DCN) •3 step test • •Gaze-evoked nystagmus test •Maddox Rod

DAI

•Discrete areas (parasagittal white matter, corpus callosum) • •Predominant mechanism of injury in most severe to moderate TBI

PT tx GBS: Patient/Family Education - manage fear and prevent further anxiety

•Disease progression, prognosis, and treatment •Answering any other questions Assume: return of function within months Maintain integrity of functioning systems, address pain, teach compensatory strategies, appropriately promote increasing activity

Pharmalogical Management

•Disease-Modifying agents: no cure, approval for Riluzole (Rilutec) a glutamate inhibitor for treatment of ALS --> Benefits are modest, extending survival 2-3 months --> Side effects: liver toxicity, asthenia, nausea, vomiting, dizziness

GBS

•Disruption of saltatory conduction leads to slowing or blocking of nerve conduction •Voltage-gated sodium channels are blocked by antibodies •Heterogeneous condition with several variant forms

Red Flags

•Dizziness with orthostatic position change •Dizziness with Loss of consciousness •Dizziness associated with other Vertebral Basilar S & S (VBI): 5 D's --> Drop, Dizziness, Diplopia, Dysarthia, Dysphagia •Sudden onset dizziness associated with: -Severe lateropulsion -Other central neurologic signs and symptoms -Headache (new and severe)

Efficiency in HEP PD

•Do 1 activity that will address multiple areas of difficulty Walking: •Fast w/ arm swing •Various directions •Stop suddenly •Up/down/over objects and ramps •Transition surfaces •Rest breaks as needed Sporting activities: •Kick boxing •Tennis/pickle ball •Basketball •You name it! Then add what isn't addressed: posture, flexibility

MS sy's Less Common:

•Dysarthria •Dysphagia •Tremor •Seizures •Breathing Problems •Hearing Loss

PD Progression: •Braak's Hypothesis

•Earliest signs are in the: •Enteric nervous system •Medulla •Olfactory bulb •Progresses to the substantia nigra and cortex over time

CVA: wrist extension

•Edema and tonal changes may produce impingement with wrist extension

MS tx must include/consider:

•Education • •Pacing/Energy Conservation •AD/orthotic/mobility aid assessment •Aerobic exercise •Strengthening •Stretching/relaxation •Consider pool FUNCTION!!!!

Viral encephalitis: Symptoms include:

•Elevated temperature •Headache •Nuchal rigidity •Vomiting •General malaise •(Symptoms of aseptic or viral meningitis) •Extensive cerebral damage (coma) •Cranial nerve palsy •Hemiplegia •Involuntary movements •Ataxia •Difficult to differentiate viral meningitis and viral encephalitis --> meningoencephalitis

•Spasticity (hypertonicity) CVA

•Emerges in about 90% of cases and occurs contralaterally -Some ppl stay in cerebral shock for a long time Spasticity associated UMN syndrome

•Horizontal Canal

•Excitation: ipsi medial rectus, contra lateral rectus

•Posterior Canal

•Excitation: ipsi superior oblique, contra inferior rectus

What Research has taught us about VESTIBULAR HEALING •Full recovery is ______ •"Cellular recovery" responsible for ______ •_____-specific •"Repair" often requires _______ of _____ pathways •Driving stimulus: error message •VSR: ____, _________

•Full recovery is movement-dependent •"Cellular recovery" responsible for re-establishment of the tonic firing rate (spontaneous) •Stimulus-specific •"Repair"often requires profound reorganization of central pathways •Driving stimulus: error message •VSR: sensory mismatch recalibration of movement cues

PD •Postural instability -What does this do to/for your patient?

•Gait •ADLs •IADLs

Alexander's Law

•Gaze toward the fast phase of the nystagmus intensifies the nystagmus

gbs •Gradual improvement of __________ to ____________ over weeks to months

•Gradual improvement of proximal to distal over weeks to months

Clinical Application of Ewald's 2nd Law

•Head in chin tuck (cranial flexion) •Focus on object •Tests ability of the VOR to hold the eyes steady even while head is moving quickly (HIT) •Finding: corrective saccade to deficit side

PathophysiologyMS

•Inflammation causes damage to oligodendrocytes •Damage to grey matter, too - often prior to white matter lesions •Damage causes scarring/plaques, which causes further damage --> Brain atrophy

Locomotor/Gait training CVA

•Integrating command centers identified in the medial medullary reticular formation Locomotor control is distributed across discrete regions of the CNS

•Caster size (identify positives and negatives)

•Large (better clearance of obstacle, catches foot) •Small (out of the way of feet, less obstacle clearance)

Modifiable Risk Factors

•Lifestyle changes •Disease management

•Not everyone can achieve symmetrical "neutral" resting posture

•Limitations in joint ROM •Muscle shortening •Spasticity •Scoliosis •Personal preferences •Functional requirements

DVT's****

• local swelling, erythema, heat

High thoracic- Level of cord injury and the degree of respiratory dysfunction

•(T2-T4): vital capacity is 30-50% of normal, cough is weak

MCA Clinical Manifestations: Nondominant hemisphere*

•(usually right): "Right CVA" •Perceptual deficits •Unilateral neglect •Anosognosia •Apraxia •Spatial disorganization

•MG symptoms typically ______ and usually reach their worst ________. •Symptoms will worsen when ______. You will see an improvement in symptoms when _____. •Each individual with MG will ______

•MG symptoms typically progress over years and usually reach their worst within a few years. •Symptoms will worsen when muscles are fatigued. You will see an improvement in symptoms when at rest. •Each individual with MG will differ, each patient is very unique.

Etiology SCI: Traumatic Injury

•MVA (38%), Fall (30.5%), Gunshot/violence (13.5%), Sports (9%)

Diagnosis: •Clinical exam MS

•Medical history •Symptoms •Neurologic exam/observation

•Symptom management MS

•Medications •Rehab to adapt and compensate for limitations

Exercise prescription PPS

•More likely to benefit less affected muscle groups

•One in___ people have MS in the US •___+ new cases are reported each week

•One in 750 people have MS in the US 200-300

ALS: •Overall incident is _____ cases per 100,000 •The incidence increases with _____ •Average age at onset is •Genders:

•Overall incident is 0.4 to 2.4 cases per 100,000 •The incidence increases with each decade of life •Average age at onset is mid-to-late 50s (50 - 70). •Men slightly more than women at 1.3 - 2:1

Medical Diagnosis PD

•no definitive test •diagnosis based on history and clinical examination •at least 2 of the 4 clinical features are present • •handwriting, speech analysis, interview, etc •exclusion of Parkinson-plus signs that are Bilateral symmetrical and do not respond to L-dopa and dopamine agonist (_apomorphine____ test) •DAT scan - Dopamine Transporters via SPECT imaging (not much better than clinical exam)

COPD:

•normally live in 85-88% SpO2 range

CVA: Visual Changes: Homonymous hemianopsia can occur with

•optic radiation and internal capsule (MCA) insult or to primary visual cortex (PCA) •Occurs in 26% of patients with CVA

ND (not determinable)=

•term used on worksheet when documenting sensory, motor, and NLI. If NT is used on any level, use ND as designation of the levels and AIS grade.

Pathophysiology of PD: •PD is associated with •They have their cell bodies in the •clinical signs emerge with ____% _____ •With dopamine reduced, we see increased _____ and decreased _____ pathway activity. Lots of _____ and decreased_____ •Decreased _____

•PD is associated with degeneration of neurons that produce dopamine •They have their cell bodies in the SNpc •clinical signs emerge with 30-60% degeneration of neurons, •With dopamine reduced, we see increased indirect (No-Go) and decreased direct (Go) pathway activity. Lots of inhibition and decreased ability to select. •Decreased automaticity

•Rolling: CVA

•PNF D1 flexion of LE can enhance mvmt •Placing patient in hook-lying and helping stabilize impaired leg can help Placing patient in hooklying by working D1 flexion pattern can be hard because of extensor tone. However, working on breaking the synergy will be helpful long-term. This is where breaking a task into component parts may be beneficial.

Sensory stimulation Guidelines

•Patients who are less aroused may require more intense and general stimulation at first, and as they become more responsive stimulation can be downgraded and become more specific (general to specific) •Make sure patient is comfortable •Eliminate distractions •Allow extra time for patient to respond •Keep sessions short, but conduct them frequently •15-30 minutes •Alternate periods of stimulation with periods of rest

•Gel

•Pressure relieving (< air) •More stable •Lower maintenance

Patient Management- Physical Therapy: GBS : Initial priorities

•Prevent complications if immobile -Contractures -Skin integrity issues •Pulmonary/respiratory function •ROM/Splinting and orthotic devices •Positioning

Changes in blood pressure (next slide

•Produce only minor alterations of CBF

Tube Feeding

•Provides nutrients to patient when unable to swallow •Tubes for nutrition are not usually removed during mobilization. •To prevent aspiration, the patient should sit up or have HOB >30⁰. •Tubes for stomach content removal are hooked up to suction. Ask RN about clearance to disconnect suction.

PT exam and intervention rancho 5-8

•Pt/family educated about diagnosis •Safety of patient and family •Functional mobility •Motor control, balance, postural control, •Self management •Strength/ endurance •Cognitive and emotional integration •Daily, social and community skills Sometimes have to have fam members unplug stove, deadbolt door, hid car keys- have to have precautions for pt fam comm safe

fx in sci (risk)

•Risk may be as high as 46% •Risk factors: female, lower BMI, complete injury, paraplegia vs tetraplegia, longer time since injury Often occurs as result of fall or forced maneuver during transfer, ADL (dressing), stretching. Can be nontraumatic TX: prevention in early stages FES, weight bearing activities (standing frame or orthotics and assistive devices) BMD of 100yo anorexic woman

Balance vestib

•Romberg •Sharpened Romberg •CTSIB •Fukuda's •Single Leg capacity •Heel-Toe capacity

Acquired brain injury

•Seizures • •Infections •Metabolic disorders •

IX: Purposeful Appropriate:

•Stand-By Assistance on Request •Acknowledges others' needs and feelings and responds appropriately with SBA •Depression may continue •May be easily irritable •May have low frustration tolerance •Able to self monitor appropriateness of social interaction with stand-by assistance

GAIT TESTING

•Standard analysis -cadence speed -gait velocity -gait quality •Tandem walking and eyes closed •Walking while turning head horizontally •Walking while tilting head up or down •Maneuvering tasks -abrupt stops, pivot turns, etc -at what cadence speed

Home program activities when using serial casting

•Standing activities for strength and balance

Discharge planning CVA

•Start discharge planning day 1 •Always involve patient and family members •FAMILY TRAINING COMPLETED!

Medical Diagnosis: •Radiographic Diagnosis •Biopsy •Laboratory Diagnosis

•Static imaging (CT, MRI) •Dynamic imaging (PET, SPECT, MRS, fMRI) •Laboratory Diagnosis: Electroencephalography (EEG)

SIDELYING TEST FOR BPPV

•Stay for 60 seconds Abnormal: •c/o dizziness •nystagmus: •latency, •<60sec duration, reverses on sitting

Postural Control and Balance*** CVA: •Balance is disturbed following stroke with impairments in:

•Steadiness •Symmetry •Dynamic stability

Medical Management brain tumors

•Surgical resection •Chemotherapy •Radiation •Stereotactic Radiosurgery

Complications/Indirect Impairments: Cardiovascular/Pulmonary

•Thrombophlebitis/Deep Vein Thrombosis (DVT)

Common gait dev CVA: stance- Hip

•Trendelenburg, scissoring

sy's MS: Secondary:

•UTI •Weakness •Posture •Bone Density •Shallow breathing •Pressure sores

In-clinic POC Recommendations MS: •During/after relapse:

•Variable timing: dependent on severity of attack and PLOF •Goal: regain function to previous level

The challenges in serial casting include:

•Varied individual response to casting •Patient's skin integrity

Exercise modalities:- CVA

•Weights •Bands/tubing •Machines - wrap foot, glove for hand, etc • • •Aquatic

26% of patients with stroke are

•are institutionalized in a nursing home

•The processing requirements of the procedural task are critical in determining the degree of expected learning deficits: block vs random PD constant vs variable

•blocked (easier- when learning) versus random practice (for real world challenge)? Constant (easier) vs. variable (real life- when retaining and applying)? For gaining skill? For retention? For plasticity? •dual tasking often causes freezing

Pharmacology PD •Additions and early treatments: MAO - B Inhibitors:

•blocks enzyme that breaks down intracerebral dopamine (selegiline = Eldepryl®, Zelapar®); used in very early PD and late to boost Sinemet effectiveness

Sensory impairments CVA: Deeper lesions (thalamus, etc.):

•diffuse involvement throughout one side of the body

Ideally: dc planning CVA

•discharge should be considered when reasonable treatment goals/outcomes are attained. Now Medicare guidelines demand discharge when daily MD and 24 hr CRRN not needed.

Maximum paralysis progresses rapidly

(two to four days), and usually involves fever and muscle pain. Deep tendon reflexes are also affected, and are typically absent or diminished; sensation (the ability to feel) in the paralyzed limbs, however, is not affected.

Clinical rating scales TBI

****DIAGNOSIS AND PROGNOSIS

Endurance training/aerobic fitness CVA

***Regular exercise may also have the additional benefit of reducing risk of recurrent stroke or heart attack Endurance training programs for patients with stroke have been shown to yield significant improvements in physical fitness, functional status, psychological outlook, and self esteem.

POC overview PPS

**Low to Moderate Intensity - non-fatiguing **Pacing and Energy conservation **Patient/family education •Rotation of types of exercises- not always working the same thing •Assistive device and bracing assessment and discussion- may not be discussion that everyone has same opinion on

MG diagnosis: Serology to ascertain for certain antibodies

- The anti-acetylcholine receptor (AChR) antibody (Ab) test is reliable for diagnosing autoimmune myasthenia gravis (MG). It is highly specific (as high as 100%).1 - Anti-MuSK (muscle-specific kinase) antibodies—found in about 50% to 70% of those who are negative for AChR antibodies and have generalized MG.

WC propulsion Recommendations:

- Use the semi-circular pattern! - Ride it out, optimize each push. - Avoid friction of hands on the wheels. - Evaluate wheelchair configuration, check out the shoulder and elbow position

Pts in a permanent vegetative state may have no meaningful motor or cognitive function and a complete absence of awareness of self or the environment for a period greater than ___ after BI and greater than ____ months after _____ brain injury

1 year 3 months; anoxic (KNOW THIS TIMELINE)

**Physical activity (MVPA) associated with an overall

35% reduction in stroke risk whereas light exercise (walking) does not appear to have the same benefit.

% dx before 50 PD

4 % diagnosed before age 50

Manual-self propulsion

1.Both hands*** 2.Using one arm and one leg 3.Using both legs 4.One-arm drive system

Seated on a mat table***: The sitting position can be used to determine the amount and location of required support.

1.Flexible: use support surface/contact points to improve posture 2.Fixed: use support surface/contact points to support and prevent worsening

Medical History Vestibular

1.Past medical history (TBI, TIA, CVA, MS, Migraine, Anxiety, Panic attacks) 2.History of current problem: onset, duration, severity of symptoms • Hearing loss, tinnitus, vertigo, aural fullness 3.Postural imbalance (and/or falls) 4.Nature and mechanism of dysfunction

Purpose of the LMN:

1Documents the medical need for the recommended equipment 2Allows the payer to understand the needs and authorize the equipment 3Provides specs for the wheelchair checkout at delivery

•Aerobic Capacity/ Endurance - MS

2 vs. 6 Minute Walk

pure motor GBS

AMAN--

UMN syndrome: Shoulder

Adduction, IR, depression Pec major, latissimus dorsi, teres major, subscap

Central Line: inserted into ____, ____ or _____ vein into _____ or _____ For: mobilize?

Central Line: inserted into internal jugular, subclavian or femoral vein into superior vena cava (SVC) or right atrium (RA). For medications, fluids and hemodynamic monitoring OK to mobilize with all central lines, including FEMORAL

Lateral medullary (Wallenburg's) syndrome: Cerebellar ataxia; gait and limb ataxia

Cerebellum or inferior cerebellar peduncle IL to lesion

Which approach needs to be considered when determining the appropriate amount and type of exercise in a patient with amyotrophic lateral sclerosis whose functional status has declined? a. Encouraging the patient to rest and exercise less so energy can be conserved b. Providing a program that includes exercises with heavy eccentric loading c. Developing a program that focuses more on the weaker muscles versus the stronger ones (weaker ones when get below 3 less impactful just leads to overuse- don't overuse weaker ones, strengthen stronger ones) d. Providing the patient with an exercise program at moderate to low intensities

D

______ associated with poorer cognitive function and lower expected outcomes

Hypoxic-Ischemic Injury (HII) [global damage]

BEDSIDE TESTS OF VESTIBULAR FUNCTION

I.History II.Eye exam and Gaze stabilization • Examination of clinical VOR function III.Nystagmus Observation/vestibular testing • Spontaneous, position, or provoked IV.Balance Quantification • VSR function V.Gait Examination •Quality and during provocative tests VI.Neurologic examination •Distal LE sensation, DTR's, muscle tone, coordination, CN VII.Rule-Out Cervical, Vascular, Psychosomatic

ICP ___ mmHg: normal > ___ mmHg: neurologic dysfunction, herniation

ICP 0-15 mmHg: normal > 40 mmHg: neurologic dysfunction, herniation

Medical Management CVA: control __ and __ with ____

ICP and herniation with anti-edema agents

What about if I'm 43 with gait instability and early freezing with no known toxic exposures or metabolic concerns?

Idiopathic or atypical- how tell difference? Apomorphine - Ldopa

Lower seat position improves propulsion biomechanics... BUT

If the seat is too low, the user is forced to push with arms abducted and shoulders elevated.

PPS: Individualized...

Individualized specific exam, evaluation and intervention plan, no two patients are alike (no one the same, they're all different)

ALS etiology:

It is hypothesized that multiple mechanisms may be responsible for neuron degeneration in ALS. No real known cause has been definitively determined.

ALS in America: ALS in Europe is called United kingdom properly calls ALS: ____ is the term used in North America

Lou Gehrig's disease Charcot's disease motor neuron disease (MND) ALS

PPMS more facts

More spinal cord lesions, fewer brain lesions, less inflammation Over 50% will require assistance with gait in 10 yrs Really no early relapses and rem- sometimes late- they happen, but not early in the process

What is the difference among palliative care, comfort care and hospice care?

Palliative care: the global word to describe all of the care that is related to relieving suffering. To palliate means to relieve or lessen without curing, to mitigate or to alleviate. A patient may go to a palliative care specialist, even though they're not dying to help them get their pain under control or to alleviate their physical symptoms. Comfort Care: care to relieve suffering for those who are dying. This term is generally used in the hospital to communicate that no more can be done to cure a loved one's disease. Hospice care: end of life care - last 6 months (voluntary vs medical care) volunteers as well as nurses, doctors, social workers, chaplains and nursing aids for symptom management medications, medical equipment and oxygen etc.

research to ambu more

POC: Activity 2x/day Inclusion Criteria: •Responsive to verbal commands •FiO2 < 60% •PEEP<10cm H2O •No orthostatic hypotension, catecholamine drips Goal: ambulate > 100ft before ICU discharge •<1% adverse events •Length of stay decreased from 13 --> 10days Goal ambu before ICU cert dist

shoulder- careful with: (CVA)

PROM, transfers, w/c activities, and gait!!!!

1st deg heart bl

PWC and mon s/s

2nd deg heart bl

PWC and mon s/s

a-fliutter

PWC and mon s/s if HR >100

a-fib

PWC if HR>100 and mon sy's

pre atrial contrac

PWC if hemodynamically unstable

supraventricular techycardia

PWC mon s/s

PVCs

PWC, mon s/s if >6

Pain - GBS

Pain - significant presenting symptom •Prominent severe pain in lower back in AIDP •72% of pt's report pain during the course of their illness •Muscle aching typically associated with vigorous or excessive exercise •Stiffness, burning, hypersensitivity to touch or even air mvmt, which can interfere with nursing care and limit therapy interventions. The types of pain reported include paresthesia, dysesthesias, axial and radicular pain, joint pain, and myalgias the pain can be neuropathic, musculoskeletal, or autonomic origin, may be related to spontaneous discharge of the demyelinated sensory nerves If sheets rub across feet feels like needles across- create tent to prevent air blowing across feet or sheets touching them

Second most common sites: pressure ulcers

Greater trochanter, scapula, elbows, ASIS, knees

greatest toes

Greatest toe- so if full afo may liit progression- if no ankle rom or strength this phase of gait often hampered (pre-swing)

CVA heart rate and rpe

HR 70-80 If beteblockers- RPE- target 17/20

Rancho Los Amigos Level of Cognitive functioning 7

Pt appears appropriate and oriented within the hospital and home; Pt shows minimal to no confusion and has shallow recall of activities. Carryover for new learning but at a decreased rate. Able to initiate social or recreational activities; judgment remains impaired. VII- more appropriate in comm, but still kind of robot-like

Rancho Los Amigos Level of Cognitive functioning 5

Pt is able to respond to simple commands fairly consistently. However, with increased complexity of commands or lack of any external structure, responses are nonpurposeful, random, or fragmented. Demonstrates gross attention to the env but is high distractible and lacks ability to focus attention on task. May converse on a social automatic level for short periods. and confabulatory. Memory impaired, shows inappropriate use of objects, unable to learn new information

Rancho Los Amigos Level of Cognitive functioning 2

Pt reacts inconsistently to stim. Responses are limited and often the same regardless of stimuli presented. Responses may be physiological changes, gross body mvmts, and/or vocalizations 2- generalized response- with noxious stim, same reaction

Rancho Los Amigos Level of Cognitive functioning 3

Pt reacts specifically but inconsistently to stimuli. Responses are directly related to the type of stimulus presented. May follow simple commands such as closing eyes or squeezing hand in an inconsistent, delayed manner. 3- localized resp- now if crush cuticle pull hand away

•Conditions that usually require supplemental O2:

Pulmonary Edema, Congestive Heart Failure (CHF), Post-Operation, Pneumonia, Shock, Chronic Obstructive Pulmonary Disease (COPD)

Horizontal or Lateral CanalRoll Testing & Interpretation: Geotropic

Roll to Right, see right beating nystagmus •Roll to Left, see left beating nystagmus • •Treatment: Canalith Repositioning modified for the Horizontal canal (BBQ)

Horizontal or Lateral CanalRoll Testing & Interpretation: Apogeotropic

Roll to the Right, see Left beating nystagmus •Roll to the Left, see Right beating nystagmus • •Treatment: Liberatory maneuver or Habituation needed

Exercise Vital Signs Criteria for terminating mobilization session Blood Pressure: •SBP >____ mmHg •> ___% decrease in SPB/DBP; orthostatic hypotension •Mean Arterial Pressure (MAP) < ___mmHg; >____ mmHg •New _____ or escalating dose of _____ medication

SBP >180 mmHg •> 20% decrease in SPB/DBP; orthostatic hypotension •Mean Arterial Pressure (MAP) < 65 mmHg; >110 mmHg •New vasopressor or escalating dose of vasopressor medication

H&Y 4

SEVERELY DISABILING DZ. Still able to walk or stand unassisted

right _____ is the same time interval as left swing.

SLS

Dorsal column-Medial lemniscal origin

Skin, joints, tendons: specialized mechanoreceptor

Brunstrom Stage Two Movement -

Weak associated movements in synergy; little or no active finger flexion

This is the most challenging task in the GC because _____

Weight acceptance 3 functional demands must be satisfied: 1.Shock absorption 2.Initial limb stability 3.The preservation of progression 4.The challenges is the abrupt transfer of body weight onto a limb that has just finished swinging forward and has an unstable alignment. Two gait phases are involved, IC and loading response

Sensory Stimulation*** (severe TBI—Rancho II/III): Proprioceptive and Kinesthetic Activities

Weight bearing and joint compression Facilitating normal alignment ROM activities Positioning changes Prone over a wedge Tilt table sidelying- go down kinda fall and see if balance rxns to react

Positive Brudzinski sign-

When the patient's neck is flexed (after ruling out cervical trauma or injury), Flexion of the knees and the hips is produced. Brudzinski's sign is a more sensitive indicator of meningeal irritation than Kernig's sign.

Creutzfeldt-Jakob disease or CJD

a degenerative neurological disorder (brain disease) that is incurable and invariably fatal. CJD is at times called a human form of mad cow disease (bovine spongiform encephalopathy or BSE) even though classic CJD is not related to BSE; however, given that BSE is believed to be the cause of variant Creutzfeldt-Jakob (vCJD) disease in humans, the two are often confused. In CJD, the brain tissue develops holes and takes on a sponge-like texture. This is due to a type of infectious protein called a prion. Prions are misfolded proteins which replicate by converting their properly folded counterparts

Osmotherapy

a medical treatment, using intravenous injection or oral administration of an agent to induce dehydration. The goal of dehydration is to reduce the amount of accumulated fluid in the brain

Symptomatic changes generally result from

a restriction of flow greater than 80%

The symptoms of meningitis are likely to include:

a very high fever, sleepiness, difficulty waking up, seizures, vomiting or nausea accompanied by a headache, confusion, difficulty concentrating, difficulty maintaining eye contact (especially in the very young), stiff neck, loss of appetite, lack of thirst, sensitivity to light, a severe headache, and in some types of meningitis, a rash.

Shoulders are aligned Spine maintains Head is Hips are flexed Knees and ankles are flexed Heels Feet Thighs are in slight Lower legs are Knees are Feet are pointing

above or slightly behind hips natural lumbar, thoracic, and cervical curves vertical and balanced over trunk with neutral horizontal visual gaze 80° to 90° near 90° directly below the knees or slightly forward or back flat on the footrests abduction vertical with neutral hip rotation pointing forward with mild symmetrical abduction forward or slightly outward

Pelvic Hike:

action of quadratus lumborum to assist with limb clearance when hip flexion, knee flexion and/or ankle DF are inadequate for limb clearance or weak iliopsoas Analysis: examine strength and ROM at knee, hip and ankle; examine mm tone at knee and ankle.

Wrist UMN syndrome:

adduction Flexor carpi radialis

Other factors associated with poor outcome: TBI

age, race, lower educational level petechial hemorrhage, subarachnoid bleed, obliteration of 3rd ventricle or basal cisterns, midline shift, subdural hematoma---also predictors of poor outcome

Neurobehavioral TBI

agitation/aggression disinhibition apathy emotional lability Mental inflexibility impulsivity

Where are We on the Continuum of Care? MS: restorative

aimed at improving impairments, functional limitations, and disabilities) After exacerbation

Where are We on the Continuum of Care? MS: Preventative

aimed at minimizing potential complications and indirect impairments) Complications and functional progression

Where are We on the Continuum of Care? MS: Compensatory

aimed at modifying the task, activity, or environment to improve function) Long Term symptoms

Intraventricular Catheter

Thin, flexible tube threaded into the lateral ventricles Drains cerebrospinal fluid (CSF) Monitors intracranial pressure (ICP) Short term: external-ventricular drain (EVD) Long term: ventriculo-peritoneal (VP) shunt

Pumps that control airflow periodically decrease and increase the When the pressure is below that within the lungs, the lungs when the pressure goes above that within the lungs, In this manner, the iron lung mimics the physiological action of breathing: by periodically altering intrathoracic pressure, it causes air to flow in and out of the lungs.

air pressure within the chamber, and particularly, on the chest. expand and atmospheric pressure pushes air from outside the chamber in via the person's nose and airways to keep the lungs filled; the reverse occurs, and air is expelled. NON INVASIVE

Untreated, bacterial meningitis is _____. With treatment, mortality (risk of death) from bacterial meningitis depends on the _______. Of newborns, ____% may die from an episode of _____ meningitis. This risk is much ___ in older children, whose mortality is about ____%, but rises again to about _____% in adults.

almost always fatal age of the person and the underlying cause 20-30 bacterial lower 2 19-37

KAFO -

although not often used, it can be indicated and successful in some people, the advantage is that you can get them walking and as tone and strength return it can be cut down. These have 3 different joints: the left is a bale/bail lock, the middle is a remote Cable lock and the last is a drop lock/ring lock. They also have offset hinge locks. There are new pneumatic and electronic locking knees coming out.

Sensory Stimulation*** (severe TBI—Rancho II/III): Vestibular:

Transfers (supine<>sit, rolling in bed) Rocking in a chair or on a mat Big Ball Bolster Rocker Board

Tensilon Test MG diagnosis

V important test- Ach- N to mm- achetocholyneesterase, gets released attaches to R, broken down by achytylcholinesterase inhibitor Inhibitor bloacks action, ach stays around longer, can attach to R, coe off and .. Inject med, watch if something improves Have to have something that can open Can be neg with people who don't have as much experience

Vibrating really helps initiate movement

UE stimulate bicep or wrist flexors or extensors. E-stim works great with Bioness Ness H200. LE: vibration works great with sidelying powder board activating quads and hamstring, looking in mirror. E-stim LE heel trigger, walk aide (innovative neurtronics), bioness Ness L300

H&Y 1:

UL minimal to no diability

Stance- Forward trunk lean:

V tight PF's- too much PF IC and LR- leg in PF, PF spasticity compensate for quad weakness; forward lean reduces knee extensor moment and thus demand on vastii. Accommodate hip or knee flexion contractures Analysis: examine quad str and hip/knee for contractures

Central Vestibular Dysfunction

Vestibular symptoms in addition to other central findings - Impaired coordination - Dysarthria, dysphagia, diplopia, drop, dizzy (decreased sensation/strength non-dermatomal) - Severe Lateropulsion* Traumatic Brain Injury Brainstem & Cerebellar Strokes MS lesions (root entry) Severe vertigo for days Differentiate from inner ear infection (What is the clinical test called) -Inability to walk -Abnormal smooth pursuit (coordination) -Normal Head Impulse Test -Abnormal Saccades -Abnormal VORc

A prion is

an infectious agent composed of protein in a misfolded form. This is the central idea of the Prion Hypothesis, which remains debated. This would be in contrast to all other known infectious agents (virus/bacteria/fungus/parasite) which must contain nucleic acids (either DNA, RNA, or both). The word prion, is derived from the words protein and infection Prions are responsible for the transmissible spongiform encephalopathies in a variety of mammals, including bovine spongiform encephalopathy (BSE, also known as "mad cow disease") in cattle and Creutzfeldt-Jakob Disease (CJD) in humans. All known prion diseases affect the structure of the brain or other neural tissue and all are currently untreatable and universally fatal.

Apraxia of speech is often present along with

another speech disorder called aphasia. Depending on the cause of apraxia, a number of other brain or nervous system problems may be present.

1.What deficit is LEAST likely to be evident with a lateral medullary stroke (Wallenberg Syndrome)? 1.Severe vertigo and nausea 2.Aphasia 3.Drooping eyelid 4.Significant Dysphagia

aphasia

Deeper pressure:

apply inflatable pressure splints that can be useful in two ways. It increases the sensory input and locks the elbow to allow weight bearing. Approximation of UE in prone on elbows, side sitting on outstretched arm, short-sitting reaching over with UE weight through swiss ball. LE approximation in standing and gait.

Motor Learning** in PD: Procedural learning deficits

are common for complex and sequential tasks (not universal)

Reduced cerebral perfusion:

arrhythmias, decreased cardiac output, hypotension, over-medication with antihypertensive meds, subclavian steal syndrome

O-Log:

assessment of orientation to person, place, time and situation [Determination of PTA] Able to predict functional independence, employment, and good overall recovery , and independent living 1 year after injury developed to measure orientation to time, place, and circumstance in a rehabilitation population. The O-Log can be used for serial assessment of orientation to document changes over time. This can be very helpful in documenting progress that could help justify continuing treatment.

Contralateral trunk lean:

assist with pelvic elevation to ensure foot clearance (functionally too long). Compensate for contralateral hip abductor weakness hip joint pain IT band tightness scoliosis Analysis: contralateral glut med str, hip pain and ITB tightness and trunk ROM. Leg length discrepancy

CRPS: stage 3

atrophic phase, pain and vasomotor changes are rare. Progressive atrophy of the skin, muscles, and bones (severe osteoporosis is evident) Pericapsular fibrosis and articular changes become pronounced. The hand typically becomes contracted in a clawed position with metacarpophalangeal (MP) extension and interphalangeal(IP) flexion. Marked atrophy of thenar and hypothenar mm and flattening of hand.

•GBS =

autoimmune AIDP

Terminal Stance: active mm

calf If hip flexion contracture shortened step lenth

Phase 3. Mid Stance Active muscle :

calf (and quads) •Ankle is at 5 degrees DF, if an AFO is ordered, in neutral, it will cause to much "braking" of the momentum by pushing the knee back if they wear flat shoes.

v-fib

call CODE BLUE

Muscle cramping:

can occur in uncommon sites such as the tongue, jaw, neck, abdomen, as well as the hands, calf or thigh

Neurological status:

can the patient follow simple commands, actively participate in therapy.

***Low system perfusion:from: (CVA)

cardiac failure the neuro deficits produced with systemic failure are global in nature with bilateral neurological deficits.

•Normally, the impulses stimulate the receptors in the ___ and ___, - VMC- readjust _____ travel thru CN's

carotid sinus and aorta peripheral resistance 9 and 10

Visceral sensory (GVA) -

carries visceral sensory information from the carotid sinus and carotid body.

Ischemic strokes produce

cerebral edema,

Secondary Injury:

chain of cellular evens following tissue damage (in addition to secondary effects: hypoxemia, hypotension, ischemia, edema, elevated ICP) Glutamate neurotoxicity, influx of calcium, free radical release, cytokines, inflammatory responses can lead to cell death. Glutamate release exacerbates on-chanel leakage---contributes to brain swelling and raised ICP

•Parkinson's-plus syndrome/atypical parkinsonism:

conditions that mimic Parkinson's disease, especially early in the course, but the symptoms are caused by other neurodegenerative disorders

H&Y 5

confinement to bed or WC unless aided

Arteriovenous malformation (AVM)-

congenital tortuous tangle of arteries and veins with interposing capillary system. •Progressive dilatation with age, 50% eventually bleed.

Yet, individuals with chronic stroke who walk slowly, at community ambulation levels, would be considered

considered too independent for US Medicare reimbursement of locomotor related therapy.

Abduction

contracture of glut med or ITB during swing, could be used to assist with foot clearance Analysis: hip abductor ROM, other factors necessitation compensation with clearance Guys who wear pants too low

Ipsilateral pelvic drop

contralateral hip abductor weakness hip adductor spasticity or hip adduction contracture Analysis: examine strength, flexibility, and tone of contralateral hip abductors and adductors

Lacunes (Lacunar Syndromes): _____ improves outcomes

control hyperlipidemia, no smoking and anti-platelet therapy improves outcomes.

TBI: ***CT and MRI findings correlate

correlate moderately with pathology and outcomes.

(GBS)What are the larger diameter motor and sensory neurons?

corticospinal and dorsal column medial lemniscus system

In walking arm in extension placed on sliding board or support surface

cuff on walker, platform walker, holding therapists hand with elbow and wrist in extension

•Predisposing factors Spastic Hypertonia*

cutaneous stimulation, tight clothing, bladder/kidney infection, fecal impaction, catheter blockage, UTI, ulcers, emotional stress

Sensory Stimulation*** (severe TBI—Rancho II/III): Olfactory stimulation:

avoid touching the skin with the scent provide stimulation for <10 seconds **there may not be a response to smell stimulation** Olfactory nerve is the most commonly injured cranial nerve in TBI Many patients have trachs, eliminates exchange of air through nostrils (no sense of smell) Nasogastric tubes block sense of smell ie: pleasant odors (after shave, cologne, perfume, flavor extracts, coffee grinds, shampoo, favorite foods) ie: noxious odors (garlic or mustard)—avoid vinegar and ammonia, they irritate the trigeminal nerve.

In motor neurons, a clustering of voltage-gated sodium channels occurs at the

axon hillock where the initial depolarization occurs. Clusters of channels also exist at the nodes of Ranvier in myelinated fibers.

Disequilibrium:

balance deficit

Locked-in syndrome (LIS) occurs with

basilar artery thrombosis and bilateral infarction of the ventral pons.

Diminished gag reflex: lat wall

be aware, often need PEG (percutaneous epigastic tube) due to high risk of aspiration.

•Ability to shiver is lost

below level of injury

GCS

best motor response verbal response

Advantages of conventional AFO include

better stabilization of the ankle, allowing improved heel-strike and push-off

Medical Management CVA: Maintain __ fxn

bladder function

Medical Management CVA: Maintain

blood glucose levels within the normal range

Visual: MS sy's

blurred, diplopia, pain w/ eye mvmnt, poor color contrast, nystagmus. Optic Neuritis: 85%

Ultra-Lightweight Manual Wheelchair Frame Options

box frame cantilever frame folding frame

From coma patients may become

brain dead, enter a vegetative or minimally conscious state, or go onto full recovery

Locomotor/Gait training: •Walking is primarily a

brainstem and spinal cord function

Rectal tube inflate

bubble end and stick up rectum- stick fairly smooth and can slip out esp if on bed and can pull on it Also if lift with U-shaped sling- the spreading it can pop out- not damaging but gross Even sometimes can be covered by sheets-

age related changes: (PPS)

by the fifth decade of life, loss of anterior horn cells begin, and by age 60 years, the loss of neurons may be as high as 50% Wiechers and Hubbell proposed that these new axonal sprouts are not indefinitely stable... ...but rather degenerate over time due to an "overexertion" phenomenon... ...resulting once again in denervation of muscle fibers.

Risk factors specific to women: cva

early menopause, estrogen increases risk of ischemic stroke, pregnancy, birth, and the first 6 weeks postpartum, preeclampsia

DVT Prophylaxis:

early mobilization, turning program, PROM, position LE's to facilitate venous return, IVC filter, compression stockings/boots, heparin/coumadin/lovenox for 6 mos.

Orthostatic Hypotension: Related problem is

edema of legs, ankles and feet; complicated by decreased lymphatic return •Use compressive stockings and abdominal binder***

•No thermoregulatory sweating,

eliminates normal evaporative cooling effects of perspiration in warm environments

Composite impairments TBI

endurance balance (sitting, standing, static, dynamic) impaired midline impaired gait impaired transfers, impaired mobility WC

RANCHO 8

endurance, CV endurance, strength, SL balance, ability to hop/path find even beyond hospital limits- can push to greater degree

If don't wear abdominal binder,

every breath is more effort- every expiration more effort- help save energy throughout day- maybe not noticeable by pts but makes a difference If don't want quad belly wear abdominal binder

Hypercarbia:

excessive carbon dioxide in the bloodstream, typically caused by inadequate respiration.

•Paralysis of _____ also influences expiration. Normally they _______to assist with forceful expulsion of air

external obliques depress the ribs and compress chest wall

Improving Motor Function: Attention to:

external rotation and distraction of the humerus

ALS Earliest markers -

fasciculations, muscle cramps, fatigue, weakness, atrophy, loss of tolerance to exercise

MG Hallmark:

fatigability in specific muscles not general fatigue. --> Muscle becomes progressively weaker during periods of activity --> Muscle function improves after periods of rest •Onset can be sudden •Symptoms are intermittent •Diagnosis may be delayed if symptoms are subtle or variable

Env adaptations: arm tray with arm placed (CVA)

flexion, abduction, neutral rotation.

Medical Management CVA: Restore/maintain

fluid and electrolyte balance

GBS: Modalities

for pain control •TENS, heat, massage, trigger point mgmt

Recommendations for mgmt of ALS:

found five areas related to the care: Goal: 1. inform pt and family re: diagnosis and prognosis 2. symptom management of sialorrhea and pseudobulbar affect 3. nutrition mgmt and PEG decisions 4. management of respiratory insufficiency and ventilation decision 5.advance directive and palliative care

FiO2:

fraction of inspired oxygen. The combination of room air plus the oxygen from the supplemental device.

Many cognitive functions controlled in

frontal lobes •TBI pt's susceptible to cognitive impairments

Spinal anesthesia is contraindicated in SCI?

fslse

infection: •Some patients have •You will be a part of •Recovery depends on •You could see patients at various stages of recovery

full recovery from infection and return to previous activities. multi-disciplinary team to assist with evaluation of deficits and recovery of function for patient. type of infection and extent of injury to brain tissue. and it may help to communicate with previous team for information.

The parenchyma are the

functional parts of an organ in the body. This is in contrast to the stroma, which refers to the structural tissue of organs, namely, the connective tissues. The brain parenchyma consists of neurons and glial cells.

rancho 5

gait, transfers........ This is a cog scores that coreelates but not 1:1

selective tightness: PPS

gives some stability to joints with paralyzed mm. Before stretch them out, carefully to evaluate functions that may be lost if gains in ROM are achieved. -contractures will resist significant elongation (20-40 years), aggressive intervention may cause more harm and functional loss. Listen to patient, they are the expert at their body, not you. Learn from each other. Sometimes a tight HS telps red knee hypertext while still allowing knock out knee- maybe not such a bad thing in no quad sr Someankle things help in maangeing weakedn mms- before stretching anything tight- consider all the ways that might actually help their fxn

Sensory Stimulation*** (severe TBI—Rancho II/III): Gustatory Stimulation:

stimulation to lips and area around mouth if defensiveness to touch (pursing lips, closing mouth, pulling away) gently continue stimulation techniques to decrease defensive reactions and increase level of awareness Be aware of diet levels and bite reflexes ie. Pleasant vs sour tastes (swab dipped in sweet, salty, or sour solution)---avoid sweet tastes if patient has difficulty managing oral secretions since sweet tastes increase salivation ie stimulation during oral care

**Facilitation of antagonistic muscles:

stroking, brushing, icing, tapping, quick stretch, vibration, e-stim

Knee Hyperextension in stance:

structural abnormality (presence of flaccid/weak quad compensated by excess PF and or posterior pull on thigh by glut max quadriceps spasticity accommodation to fixed PF deformity Analysis: examine strength of vastii; tone, spasticity of PF and quad; ROM and knee proprioception

CRPS: stage 2

subsiding pain and early dystrophic changes: muscle and skin atrophy, vasospasm, hyperhidrosis, and course hair and nails. Radiological evidendence of early osteoporosis

*** over time, gradually reestablishes

sufficient vasomotor tone to allow assumption of the vertical position.

Physical Therapy Exam: MS: Sensation (and skin integrity):

superficial and deep touch, temperature

CRT for Horizontal Canal BPPV Canalithiasis:

supine roll maneuver or "BBQ Nystagmus: Transient (<5 minutes) geotrophic, symptomatic 89% success

PPS Can be "triggered" by recent events -

surgery, fall, recent inactivity

In SCI: greater dysfunction from

swelling within canal (referring to ICP?)

Sensory Stimulation*** (severe TBI—Rancho II/III): Tactile stimulation:

tactile input can be facilitatory or inhibitory face (especially lips and mouth) are the most sensitive use unpleasant stimuli (pinprick) with caution (avoid ice to face or body, can trigger a sympathetic nervous system response: vary degree of pressure (firm vs light tough) ie (for example): sternal rub various textures (clothing, blankets, stuffed animals, lotion) vary temperature (warm or cool clothes, metal spoon dipped for 30 seconds in hot or cold water.

M/L hip strategies are promoted by

tandem stance

Greatest gains in locomotor recovery after stroke may be associated with training interventions that are

task-specific and have high-intensity demands such as step training at speeds faster than an individual's known capability overground

Pharmacology PD: Anticholinergic Agents:

greatest effect on tremor and dystonias; decrease activity of acetylcholine; used early in process or as adjunct with levodopa;

Strength/endurance:

gross and fine motor skills for w/c management. How does endurance affect, can they function well for an hour but need max A when tired in afternoon?

More than ___of manual wheelchair users will develop upper extremity overuse injuries or pain during their lifetime

half

cva BP < 120/80 mm Hg have

half the lifetime risk of stroke than those with hypertension

Maintenance of postural alignment may require such additions as a:

head support, lateral supports for the trunk, hips, and knees; medial support for the knees, UE support surfaces as well as straps (anterior chest or pelvis)

The most common symptoms of meningitis are:

headache and neck stiffness associated with fever, confusion or altered consciousness, vomiting, and an inability to tolerate light (photophobia) or loud noises (phonophobia)

•Symptoms hydrocephalus

headache, nausea, vomiting, visual impairment, increasing lethargy, ataxia.

•Both hemorrhagic and ischemic stroke can result in severe ____ pain

headache, neck or face

Disadvantages of conventional AFO include

heavier weight, less cosmetic appearance, and increased difficulty donning and doffing.

*most common long-term deficits of CVA

hemiparesis (50%) inability to walk without assistance (30%) dependence in ADLs (26%) aphasia (19%) depression (35%)

Excess hip flexion Mst thru PSw:

hip flexion or knee flexion contracture or spasticity weak PF failing to control excess tibial advancement painful or effused hip. (painful hip, swollen hip) analysis: examine tone and spasticity of hip/knee flexors; ROM hip /knee; str PF and hip for joint point

MG: Weakness --> waddling because

hip is proximal and hip abductors in general weaker

Ankle Dorsiflexion:

hips and knees should be positioned in available hip flexion and knee extension alignment. Ankle should be maintained in a neutral inversion/eversion position and an neutral DF/PF

The rupture of a blood vessel leads to

the compression of brain tissue from the expanding hematoma, this reduces blood supply to the tissue and leads to ischemia

Terminal Swing:

the knee extends; the limb prepares to contact the ground for Initial contact

MVA as a cause of TBI have

historically ranked higher, however, recent data shows that this trend of falling motor vehicle rates has resulted in Falls surpassing MVA/traffic as number one cause of TBI

Following casting, the therapeutic program includes:

home stretching, bi-valved casts used as night splints for prolonged stretching, and ongoing physical therapy treatment for strengthening and functional mobility training.

Tone reducing: MS

hydrotherapy, NMES, ice/heat, trunk rotation, intermittent static stretching, prolonged stretching, serial casting

Vertigo:

illusion of movement

v-tach

immed d/c ther, not med staff asap if >6in row

NT- reasons

immobilization,

composite imp als

impaired sitting tolerance, impaired sitting balance

Bulbar palsy refers to

impairment of function of the cranial nerves IX, X, XI and XII, which occurs due to a lower motor neuron lesion either at nuclear or fascicular level in the medulla oblongata or from lesions of the lower cranial nerves outside the brainstem.[1]

Port-a-cath:

implanted under the skin, connected to a catheter which terminated in the superior vena cava

Pathophysiology cva: Complete cerebral circulatory arrest results in

in irreversible cellular damage with a core area of focal infarction.

•Vasodilation does not occur

in response to heat nor vasoconstriction in response to cold

10-15% of pts with severe TBI discharged in

in vegetative state, prevalence of minimally conscious state is greater than vegetative

Postural Control and Balance***: CVA Central sensorimotor processing problems =

inability to adapt postural mvmts to changing task and env. demands and impair motor learning

If foot drop-

increase knee and hip flexion- steppage gait

Stepping are promoted by

increased displacements of the COM (A/P or sideward leans that move the COM outside of the BOS). Apply an elastic band around the hips, offering resistance to the forward lean. Resistance that is quickly released once the patient achieves the desired lean will necessitate a step to control balance. Step-ups should also be practiced.

ALS PT Intervention: Compensatory:

increasing the number of adaptations through their disease course to maintain as much function as possible.

Area of dysfunctional tissue can progress to

infarction

•GBS: This immune response leads to an ____ and _____ in the _____

inflammatory process and destruction of the myelin sheath larger diameter motor and sensory neurons

Diphosphonates and NSAID (indomethacin) shown to

inhibit formation of calcium phosphate to prevent ectopic bone formation.

Weaning trials:

initially schedule mobilization when patient is back on ventilator.

pain sci Neuropathic-

injury to central or peripheral nervous system May occur above, at, or below SCI. Allodynia or hyperalgesia Nerve root pain Spinal cord dysesthesias Treatment? valproic acid (Depakote), amitriptyline (Elavil

Spastic Hypertonia*: altered...

input at the spinal segmental level •Imbalance between excitation and inhibition •Anterior horn cell may become hyperexcitable •Descending, suprasegmental signals altered/ eliminated after SCI •Changes in afferent input

•Peripheral Line:

inserted into hand, wrist or cubital fossa •For medications/fluids. That location gets sore after 2-3 days

TBI: 80,000-90,000 develop ______ preventing independent lifestyle

intellectual, behavior, physical disabilities

In fast conducting myelinated neurons, propagation of the action potential relies on the

interaction between the nerve axon and myelin.

Expected outcomes of serial casting include: If appropriate, increased ease of fit

into ankle foot orthotics for positioning during rest, stance, or ambulation

Edema can elevate ICP -->

intracranial HTN and neurological deterioration

Nystagmus:

involuntary eye movement at rest or with mvmt

Contralateral pelvic drop

ipsilateral hip abd weakness, hip add spasticity, or hip add contracture analysis: examine strength, flexibilty, and tone of ipsilateral hip abductors and adductors

Asthenia:

is a medical term referring to a condition in which the body lacks or has lost strength either as a whole or in any of its parts. It denotes symptoms of physical weakness and loss of strength.

Reye's syndrome:

is a potentially fatal disease that causes numerous detrimental effects to many organs, especially the brain and liver, as well as causing a lower than usual level of blood sugar (hypoglycemia). The classic features are a rash, vomiting, and liver damage. The exact cause is unknown and, while it has been associated with aspirin consumption by children with viral illness, it also occurs in the absence of aspirin use.

Blepharoptosis (MG)

is an abnormal low-lying upper eyelid margin with the eye in primary gaze. Normally, the upper lid covers 1.5 mm of the superior part of the cornea. Skin redundancy of the upper lid, or dermatochalasis, is a separate finding, and may occur in conjunction with blepharoptosis.

Kuru:

is an incurable degenerative neurological disorder that is a type of transmissible spongiform encephalopathy, caused by a prion found in humans. The term "kuru" derives from the Fore word "kuria/guria" ("to shake"), a reference to the body tremors that are a classic symptom of the disease; it is also known among the Fore as the laughing sickness due to the pathologic bursts of laughter people would display when afflicted with the disease. It is now widely accepted that Kuru was transmitted among members of the Fore tribe of Papua New Guinea via cannibalism

Bacterial meningitis

is much more dangerous and can be fatal if not treated quickly with antibiotics. Most cases are caused by three different types of bacteria.

The transitional area surrounding the core

is termed the ischemic penumbra and consists of viable but metabolically lethargic cells.

Visual agnosia

is the inability of the brain to make sense of or make use of some part of otherwise normal visual stimulus and is typified by the inability to recognize familiar objects or faces. Visual agnosia is often due to damage, such as stroke, in the posterior occipital and/or temporal lobe(s) in the brain.

Nuchal rigidity:

is the inability to flex the neck forward due to rigidity of the neck muscles; this is indicative of an irritated lesion of the subarachnoid space. Signs of meningeal irritation are painful cervical flexion bc it stretches the inflamed meninges, nerve roots, and spinal cord. The pain triggers a reflex spasm of the next extensors to splint the area against further cervical flexion.

Bitemporal hemianopsia

is the medical description of a type of partial blindness where vision is missing in the outer half of both the right and left visual field. It is usually associated with lesions of the optic chiasm, the area where the optic nerves from the right and left eyes cross near the pituitary gland.

Viral meningitis

is the more common and less serious form -- it usually clears up on its own in 7 to 10 days.

•Prognosis GBS

is typically very good!!!

*****Supplemental oxygen must be used with caution because ALS

it can suppress respiratory drive, exacerbate hypoventilation, and ultimately lead to hypercarbia and respiratory arrest.

*In humans true decerebrate rigidity is rare because

it is an injury that is often lethal

Excess knee flexion in All phases

knee flexor spasticity or contracture that exceeds position required for given phase painful or effused knee proprioceptive loss at knee shorter LE on contralateral side. Consider weak calf or hip flexion contracture if it occurs during SLS Analysis: examine tone, spasticity and ROM; and for pain, effusion, proprioceptive loss at knee; leg length discrepancy

Disorganized problem solving

l

Flexible afo with

lmn foot slap

Instead of withdrawing or posturing to noxious stimuli, pts in a minimally conscious state will

localize to noxious stimuli If mother comes in might look to them (in veg wn do that) Likely pull hand away if crush cuticle

Mineral and plasma protein

loss

Diaschisis:

loss of function and electrical activity due to cerebral lesions in areas remote from the lesion but neuronally connected to it.

direct als

loss of functional motor units, loss of ROM

•Autonomic (sympathetic) dysfunction results in

loss of internal thermoregulatory responses.

Cachexia (kekeksia):

loss of weight, muscle atrophy, fatigue, weakness, and significant loss of appetite in someone who is not actively trying to lose weight. The formal definition of cachexia is the loss of body mass that cannot be reversed nutritionally: Even if the affected patient eats more calories, lean body mass will be lost. -failure to thrive -difficulty swallowing often leads to losing a lot of weight

WC CVA: Families trained in

maintenance and care as well as breaking chair down and taking patient up and down stairs/curbs Train in how to adjust brakes, leg rests, removing armrest, fixing flat if pneumatic tires are used. Always consider if they can purchase a lift or device to carry the wheelchair on their vehicle.

Brunstrom•Stage Three- mvmt

mass grasp in hand

Performance Oriented Mobility Assessment (Tinnetti):

max score 28 <18 high fall risk 19-24 moderate fall risk >24 (25-28) low fall risk

Limited hip flexion (IC and LR 20deg flexion)

may be intentionally to limit demand on weak hip extensors during LR weak hip flexors, or single joint hip extensor hamstring spasticity or contracture limiting terminal swing advancement before initial contact analysis: str of hip flex and ext; ROM of hip and for spasticity of hip extensors and hamstrings

a normal plantar response

may be present several weeks before deep tendon reflexes are apparent in the LEs

Minimal to moderate spasticity:

may learn to trigger spasms to assist in functional activities

Motor impairment GBS

may vary from mild weakness of distal LE mm to total paralysis of the peripheral, axial, facial, and extraocular mm.

Modern treatments of stroke involves

measure to help recovery of dysfunctional tissue

Gait training: •Focuses on improving the

mechanics and quality of walking

Coxsackie and echoviruses:

meningeal cells

Pts in a permanent vegetative state may have

no meaningful motor or cognitive function and a complete absence of awareness of self or the environment for a period greater than 1 year after BI and greater than 3 months after anoxic brain injury

Macrophages function in both

non-specific defense (innate immunity) as well as help initiate specific defense mechanisms (adaptive immunity) of vertebrate animals. Their role is to phagocytose (engulf then digest) cellular debris and pathogens. They also stimulate lymphocytes and other immune cells to respond to pathogens (GBS)

Evidence to suggest any vestibular suppressant medications as a definitive primary treatment for BPPV or as substitute for repositioning. Clinicians ______ substitute pharmacological treatment of symptoms of BPPV for effective treatment maneuvers

none should not

Expectations: unrealistic goals: (WC)

normalize posture, total pain relief, allow independent transfers. ( if unrealistic goals are not discussed and met, disappointment can overshadow the other benefits of the system.)

•GBS: The cause is _____, it is a syndrome rather than a disease because _____

not clear it is not clear that a specific disease-causing agent is involved.....

coma is defined as

not obeying commands, not uttering words, and not opening the eyes.

Coma is usually

not permanent

head array

not proportional

infections- The classic triad of diagnostic signs consists of

nuchal rigidity, sudden high fever, and altered mental status; however, all three features are present in only 44-46% of bacterial meningitis cases.[5][6] If none of the three signs are present, meningitis is extremely unlikely.

Physical Therapy Interventions: Compensatory training strategies -

promote resumption of function faster, independence for fast discharges, for severe motor impairment and limited recovery.*****

•Sitting on therapy ball can help encourage (CVA)

proper posture and righting reactions (gentle rolling) and increase tone (gentle bouncing)

Other loss sensory CVA

proprioception, motor control, posture, balance

TBI: Neuropsychological testing is often done as well to

provide further insight into cognitive and behavioral deficits

*High cervical injuries:

pulmonary problems are the leading cause of death both in early and late stages of recovery

Backward trunk lean in stance or swing

purposeful to reduce demands on weak stance limb glut max or to assist with limb advancement when hip flexion capability is limited Analysis: examine hip extensor and flexor strength

ADMINISTRATION AND SCORING: The Orientation Log (O-Log) is designed to be a

quick quantitative measure of orientational status for use at bedside with rehabilitation inpatients. Place, time, and situational (Etiology/Event + Pathology/Deficits) domains are assessed. Patient responses are scored according to the following criteria: 3 = correct spontaneously or upon first free recall attempt; 2 = correct upon logical cueing (e.g., "That was yesterday, so today must be ..."); 1 = correct upon multiple choice or phonemic cuing; and 0 = incorrect despite cueing, inappropriate response, or unable to respond.

DVT hallmark:

red, painful, swollen (Homan's) •TX: blood thinners, heparin, compression boots

Medical Management CVA: improve cerebral perfusion by

reestablishing circulation and oxygenation

The Kernig sign:

refers to a test performed with the client supine in which the thigh is flexed on the abdomen and the knee extended. If it can't be extended it is a positive test. Complaints of lumbar or posterior thigh pain indicate a positive test result. This movement pulls on the spinal cord which pulls on the covering of the spinal cord, causing pain in the presence of meningeal irritation. Same as the SLR performed to identify

Allodynia

refers to central pain sensitization (increased response of neurons) following painful, often repetitive, stimulation. Allodynia can lead to the triggering of a pain response from stimuli which do not normally provoke pain

MG •Plasmapheresis and IVIG:

remove putative antibodies in the circulation, or bind the circulating antibodies (the treatment is effective only for a few weeks; used as short term treatment)

The Modified Ashworth scale (MAS) measures

resistance during passive soft-tissue stretching and is used as a simple measure of spasticity.

•Evidence exists to support connections with ______ (GBS)

respiratory or GI viruses and Epstein-Barr virus.

CVA Slow rocking movements:

rocking the body over the elongated limb (quadruped with arm in weight bearing and rocking A/P, M/L) placing the body in prone over large swiss ball and do gentle rocking for highly spastic TBI

Hemorr CVA: •The result of

rupture of a cerebral vessel or trauma •Increased intracranial pressures with injury to brain tissue, and restriction of distal blood flow.

rancho 2

rxns to noxious stim, ROM, tone, skin integrity, start assessing things 3 would get

Most common sites: pressure ulcers

sacrum, coccyx, heels, ischium,

Action potentials are generated at the nodes by opening of the voltage gated sodium (Na) channels leading to an influx of Na+ ions which depolarizes the membrane. Closure of the Na+ channels terminates the action potential by restoring the resting membrane potential. This process is called

saltatory conduction and allows the current to spread further and quicker between nodes thus speeding up the action potential.

If I have parkinsonism symptoms and was a methamphetamine user, which type of PD do I likely have?

secondary

Meclizine (Antivert, Bonine)

sedating ***For acute bouts of vestilbular neuritis and Meniere's, about 3 days is appropriate. about 3 days is appropriate

•Community services (CVA dc planning)

should be identified and follow-up should be established

Upper Extremity- one of strongest componenet extension oblig synergy

shoulder adduction

Excess hip flexion IC:

single jt hip extensor weakness (glut max, adductor magnus) with compensation by hamstring severe hip and/or knee flexion contractures hypertonicity of hip or knee flexors (increased tone hip flexors) analysis: examine single jt hip ext and hamstring str; hip and knee flexion ROM, tone, and spasticity

• Most common:

single loop over

Medical Management CVA: •Maintain integrity of

skin and joints

•Activation of antagonist mm using ______. Facilitation of weak antagonist muscles helps reduction of tone through _______.**

slow and controlled mvmts. effects of reciprocal inhibition

Extra ocular eye exam:

smooth pursuit, saccades, VOR cancellation

}MRI provides superior _____ compared to CT

soft tissue discrimination

HIP External Rotation:

spasticity or contractures of ER; weakness of IR Analysis: examine tone, external rotation ROM, str of IR

HIP Internal Rotation:

spasticity or contractures of int rotators weakness of ex rotators excessive forward rotation of contralateral pelvis Analysis: tone, IR ROM, str of ER

CIMT:

stable transfers, 90% of waking hours, 2 weeks

Stage 2-brunstrom

start to come out of cerebral shock and start to dev synergy

Blast Injury:

transient shock wave produced from explosive device, causing blast overpressure on organs

Autonomic imbalance leads to splanchnic vasoconstriction?

true

Good bowel care may reduce incidence of AD?

true

To get good pelvic and spin alignment, we often either have somebody sit behind the patient,

turn sideways and use hip or leg to apply slightly/heavy pressure into low back and pull shoulders backwards. Alternative: place gait belt around patient's low back and around therapist's back, therapist shall pull backwards to increase lordosis and anterior pelvic rotation of patient.

III. Flouren's law:

unique hard-wired VOR connections •roll/pit ch//yaw •The inner ear must be able to register rotation about these three axes. The three semicircular canals -- the anterior, posterior and lateral canals, are arranged nearly perpendicularly in order to measure rotation in 3D space.

diencephalon appears at the

upper end of the brain stem, situated between the cerebrum and the brain stem. It is made up of four distinct components: the thalamus, the subthalamus, the hypothalamus, and the epithalamus

MS Relapses are

variable and unpredictable: symptoms, severity, duration, timing, degree of recovery

rancho 7

variable tasks- on the verge but not into learning new things that well- basic path finding- can they find their way to front, can they get back to room

CRPS: stage 1:

vasomotor changes, discoloration (pale pink or cool) and alternation sin temp. Skin is hypersensitive to touch,pressure or temp variations. Pt usually guards against mvmt attempts

Vent mode: AC: assist control:

ventilator supports every breath (fixed rate, controlled volume, dialed in FiO2), whether it's initiated by the patient or the ventilator. Used to allow pt to rest: used with acute respiratory distress syndrome (ARDS), paralyzed or sedated.

Vision and Hearing: WC

vision affects the ability to drive a power w/c and maneuver a manual w/c. May be of more consequence outdoors. (hearing : driving outdoors)

No heel off at TSt and/or PSw

weak invertors (fail to lock midfoot in TSt), inadequate toe extension ROM; painful forefoot/toes Analysis: Examine strength of PF and tibialis posterior; toe extension ROM (esp. first metatarsal phalangeal jt), forefoot pain

Medication side effect of

weakness, dizziness, drowsiness. May develop tolerance. CNS depression and sedation

Medical Research Council (MRC CRASH -corticosteroids randomization after significant head injury):

web-based calculator allowing clinicians to enter demographic, prognositic (country, age, GCS, pupil reactivity, cranial injury, CT finding)=calculates 14-day mortality risk and unfavorable outcomes at 6 mos with a 95% CI. Unfavorable=vegetative, severe disability on Glasgow outcome scale (GOC)

Abnormal sensory result (NT, 0, 1) occurs

well above the sensory level and the weakness is non-SCI.

ICP- After trauma, brain cannot auto-regulate blood vessels. Activity may ↑ ICP. Avoid mobilization when _____. When stable, ask MD to OK temporarily ______. Maintain _______

when pressure has not stabilized. When stable, ask MD to OK temporarily closure of CSF drain. Maintain HOB >30⁰

•There is a relatively benign form of the lateral medullary syndrome seen in young adults following exercise

which has an excellent long-term prognosis. (vertebral artery dissection may be from heavy weightlifting)

T cells or T lymphocytes belong to a group of

white blood cells known as lymphocytes, and play a central role in cell-mediated immunity. They can be distinguished from other lymphocytes, such as B cells and natural killer cells (NK cells), by the presence of a T cell receptor (TCR) on the cell surface. They are called T cells because they mature in the thymus. There are several subsets of T cells, each with a distinct function. (GBS)

cerebral edema •begins

within minutes and reaches a maximum by 3-4 days).

Often see horseness and hiccups from

x nerve nucleus involvement (The most common cause of long-term hiccups is damage or irritation of the vagus nerves or phrenic nerves, which serve the diaphragm muscle. (lat wall)

another factor that decides TBi prognosis is

years of education, family support, if there was any alcohol or drugs in the system at the time of the injury

Young stroke:

younger than age 45

The health of the neuron from the proximal to the distal end is maintained by

zonal transport.

Incidence of vestibular damage following chronic Whiplash Associated Disorders (WAD) (>3-6 months)

}40% incidence of canal paresis }50% incidence of vestibular dysfunction (30% BPPV & 20% canal paresis) }BOTTOM LINE: Patients with chronic dizziness secondary to WAD need to be screened for vestibular disorders and for possible BPPV even acutely

Diagnosis TBI

}CT scans are useful in identifying ventricular enlargement and atrophy, CT is relatively insensitive to many of the lesions present after trauma }There are also CT MRI PET, SPECT and fMRI

Alterations in sensation are common (TBI)

}LIGHT TOUCH }Pain }DEEP PRESSURE }Temperature }PROPRIOCEPTION/ KINESTHESIA }Ambulation and other mobility skills (secondarily impaired-doesn't know where body is in space) }Impaired balance (secondary to proprioception, visual and/or vestibular impairments)

Acute Paralytic Polio**

§Flaccid paralysis Proximal>distal

Surgical management PD: Duopa

ØTube into the small intestines- red lev/carb, but other side effects- duopa more prob's with constipation though ØGel formulation of carbidopa/ levodopa

Spasticity Management: Rhythmic rotation

to gain initial range (gently rotate segment back and forth), once range is gained, limb is positioned in lengthened position and held several minutes (5-10 min) or placed in supported weight bearing

Train center-of-mass (COM) by (CVA)

• exploring limits of stability (LOS), learn how to keep COM in base of support (BOS) Once postural alignment and static stability is achieved in upright postures, the patient is ready for center-of-mass control training.

SCI etiology trend due to:

• improved emergency medical services (meds) • seat belt/air bags

Postural hypotension

•(Orthostatic hypotension): decrease in BP when assuming an erect or vertical position •Caused by loss of sympathetic vasoconstriction control •Enhanced by lack of muscle tone, causing peripheral venous and splanchnic bed pooling •Reduced cerebral blood flow and decreased venous return to the heart cause symptoms of lightheadedness, dizziness, fainting

Pharmacology PD: Amantadine

•(Symmetrel) used early to treat tremor and late in treatment to manage dyskinesias

Pharmacology Primary Dopaminergic/Dopamine replacement: Dopamine Agonists:

•(mimic dopamine to post-synaptic dopamine receptors) Requip, Mirapex, Neupro Greatest effect on RIGIDITY and BRADYKINESIA; May have disease modifying effects, but inconclusive evidence; Less potent, but less likely to cause dyskinesias

MS Pain -

•- 55% clinically significant

The greatest potential for functional recovery may be possible for chronic stroke patients who have reached casual walking velocities above

•0.5 m/s

Modified Ramsey Scale of 1-6

•1 = agitated •2-3 = appropriate for PT •6 = unresponsive

BWSTT: •Assistance required and it can be intensive and exhausting

•1 provides manual assistance at foot/ankle/knee on impaired LE •1 stands behind pt and provides manual assistance to pelvic rotation/weight shift and prevent "swinging" •1 often needs to help timing and placement of sound limb

•If abnormal always supports a CENTRAL DEFICIT

•1.Smooth pursuit •2.Saccade •3.Vestibular-Ocular Reflex Cancellation (VORc)

•10 years post, Tetraplegia**

•10 years post, 26.4% were employed For all spinal cords together, 88.3 % returned to private residence, 5.1% discharged to nursing homes. Because most are young, 53% were single at the time of injury

Post-traumatic seizures TBI

•12-50% of those with severe TBI What is the most common side effect of anti-seizure medications? DIZZINESS* Headache* Vertigo* Ataxia* Blurred vision* Tremor*

Incidence MG

•14-20/100,000 in the US. •Rising incidence as a result of increased awareness •Occurs in all races, genders, ages. •Not contagious •Not directly inherited •Usually average age of Onset after 20 -50's. Previous studies have shown that women are more often affected than men. The most common age at onset is the second and third decades in women and the seventh and eighth decades in men. As the population ages, the average age at onset has increased correspondingly, and now males are more often affected than females, and the onset of symptoms is usually after age 50.

gbs •1st symptoms:______, _______, _______, ______

•1st symptoms: pain, numbness, paresthesia, weakness

Fall Risk PD

•2/3 of patients with PD experience falls •13% falling more than once a week •rate of fall injury is 40% •Contributing factors to falling: - freezing - poor gait - balance impairments - Dementia - Depression - Postural hypotension •Involuntary mvmts (long-term use of anti-parkinsonian meds)

GBS: vent ... d/t....

•20-38% require assisted ventilation due to paralysis of intercostal and diaphragm

•Acute care LOS •Inpatient rehabilitation

•24 days in 1970s to 11 days in 2016 98 days in 1970s to 35 days in 2016

Gait - Rehab:•Assessment MS

•25'/10m walk •MMT before •6 min walk •Tinetti •TUG •DGI/FGA Safety/•environment/task eval

Circulating Vaccine-Derived Polio Virus

•2nd strain eradicated in 1999, but still in trivalent oral vaccine (weakened, but still live virus) • •Have moved to bivalent oral vaccine as greater than 85% of cases are of type 2

Meningiomas

•33% of reported brain tumors •Slow-growing •2:1 females to males

Cognition Impairments ALS

•35.6% of patients with ALS show clinically significant cognitive impairment --> Frontotemporal dementia (FTD) reported and characterized by: •Cognitive decline, executive functioning Impairments, difficulties planning, organization and concept abstraction, and personality and behavior changes •Patients with bulbar-onset ALS are more likely to have cognitive impairments than patients with limb-onset disease

polio- nonparalytic Aseptic Meningitis

•4-10% of polio affect outer meninges •2-10 days, full recovery

MS Cognitive Impairments -

•40-60% •Short-term memory, executive function, attention, organization, problem solving

•Low Tetraplegia (C5-8) Life Expectancy

•40.7 years (total 60.7 years)

•Complete paraplegia Life Expectancy

•45.5 years (total 65.5 years)

of CVA's develop DVT's,

•47%

acute research stats

•47% had neuromuscular abn •28 patients developed myopathy, polyneuropathy or both in ICU. •51% failed to return to work d/t persistent fatigue, weakness, poor mobility, pain.

•______% of persons who survive an initial stroke will experience another one within 1 year, (in 5 years ____%)

•5-8% of persons who survive an initial stroke will experience another one within 1 year, (in 5 years 16%)

Resting Vital Sign: Acceptable Parameters: HR

•50 < HR < 120 bmp at rest

•People with severe TBI develop:

•50% with gastrointestinal •45% with genitourinary •34% respiratory •32% cardiovascular •21% dermatological complications

Life Expectancy: •Incomplete injury (sustained at age 20)

•52.9 years (total 72.9 years)

Types of MS - RRMS

•85% of ppl initially diagnosed with this type •No progression during remissions •active/inactive (relapses or evidence of new MRI activity) [Active/inactive- how frequently having relapses]

Multiple Sclerosis

•A chronic, unpredictable, frequently progressive immune-mediated disease that causes inflammation and damage to the CNS, including the brain, spinal cord, and optic nerves. Damage is typically to myelin sheath, and sometimes the axon, which interrupts nerve signal conduction.

MG diagnosis

•A firm diagnosis can take months or even years •Unusual and fluctuating symptoms cause patients to be screened/worked up for: MS, brain tumors, CVA, infection, intracranial pathology, etc.

Patient Management- Therapy: •ALL activity and exercise needs to be: •Over-fatiguing the affected motor unit may: •High resistance exercises may: •Also seen with: •May increase muscle: •Hypermobility:

•ALL activity and exercise needs to be a gradual graded progression - listen to your patient and don't push! • •Over-fatiguing the affected motor unit may impede recovery and cause weakness •High resistance exercises may increase demyelination •Also seen with increased exercise intensity •May increase muscle tenderness and pain • •Hypermobility - joint dislocation due to muscle flaccidity

•ALS is a ____ (0.4 to 2.4 cases per 100,000) ______ neurologic disorder with an unknown cause and no known cure. •Individuals with ALS typically live _____ from diagnosis. •To be diagnosed ____ and ____ must be involved in ___ regions of the body. (Know the different signs) •Symptoms often begin _____ and spread _______ before _____ or _______. •Cranial nerve (brainstem nuclei) function as well as cognition and respiration ______ •Most individuals die due to ______ •Sensation, external ocular muscles and bowel and bladder control are _____ ________ then pertain to secondary impairments. (later) •Speech therapy should be involved due to _______. •Patients and therapists must _______ •Therapeutic intervention should focus on ______ •Little research exists, but it is believed that ______ exercise is beneficial as long as overuse fatigue is avoided. •_______ is a vital component of therapeutic intervention.

•ALS is a rare (0.4 to 2.4 cases per 100,000) progressive neurologic disorder with an unknown cause and no known cure. •Individuals with ALS typically live months to 5 years from diagnosis. •To be diagnosed UMNs and LMNs must be involved in 3 regions of the body. (Know the different signs) •Symptoms often begin unilaterally and spread at the same level before ascending or descending. •Cranial nerve (brainstem nuclei) function as well as cognition and respiration may also be involved. •Most individuals die due to respiratory failure. •Sensation, external ocular muscles and bowel and bladder control are often spared. Prevention/restoration then pertain to secondary impairments. •Speech therapy should be involved due to eventual speech and swallowing concerns. •Patients and therapists must look ahead when planning treatment and ordering devices. •Therapeutic intervention should focus on those things that matter to the patient (living will). •Little research exists, but it is believed that moderate exercise is beneficial as long as overuse fatigue is avoided. •Patient and family education is a vital component of therapeutic intervention.

Indications for testing EOM:

•ALWAYS

OM's in acute

•AM-PAC IMSF •TUG •PASS •10 MWT •DGI •FGA •POMA •BBS •FSS-ICU •PFIT-s

•Primary muscles of Expiration:

•Abdominals (T6-T12) and internal intercostals

House Walker

•Able to walk throughout home •No w/c at home •Difficulty on stairs •100-2,499 steps/day • •6MWT: <205 meters

WC •Discomfort leads to:

•Abnormal tone •Abnormal movement •Abnormal postural asymmetry •Fatigue •Decreased endurance •Decreased attentiveness/concentration Disuse of the equipment

Neuromuscular impairments

•Abnormal tone, motor function, gait, UE/LE paresis, coordination, postural control, paresis (life-long impairments)

Types of MS - PPMS

•About 15% of people with MS •No early relapses or remissions •Can be characterized as either active/inactive (occasional relapses/evidence of new MRI activity) •Can also be characterized as with/without progression (evidence of disability accumulation over time, with or without relapses)

polio •Abortive

•About 70% have no symptoms •25% mild infection •Slight fever, headache, sore throat, vomiting, constipation, and diarrhea •Full recovery 24-72 hrs

Normal Recovery and Prognosis CVA: -phys of how happens -Functional gains possible ____, however, _____: changes d/t _____

•Absorption of damaged tissue •Improved local circulation and cellular metabolism Allows intact neurons that were previously inhibited to regain function. Functional gains possible months to years post stroke, however, at a slower rate: changes due to function-induced plasticity.

Diffuse Axonal Injury (DAI): ______ cause DAI

•Acceleration, deceleration, and rotational forces cause DAI •Axonal changes eventually lead to their separation from the soma

•Medication: MG

•Acetylcholinesterase inhibitors -ACh will then accumulate in the neuromuscular junction allowing its effect to be prolonged. •Immunosuppressive drugs

•Released metabolites cerebral BF

•Act directly on smooth mm in local vessel walls

"The New Polio"

•Acute Flaccid Myelitis •Inflammation of spinal cord causing paralysis of limbs, neck, face and diaphragm • •Assumed to be virus, with 2 identified candidates, but not ubiquitous

Fatigue MS

•Affected by heat and humidity (2 degrees)

•Racial Considerations:

•African Americans have lower Hgb and Hct levels and are more prone to anemia.

Wheelchair testing

•After optimal positioning is determined—consider functional needs of the user •Time should be allowed for testing trial equipment •Don't test equipment unavailable to the patient •Training of pt/family for safety with mobility skills •Training of pt/family upkeep of wheelchair

ALS Prognosis

•Age at time of onset has the strongest relationship to prognosis •Patients less than 35-40 yo at onset, had better 5-year survival rates than older individuals. •Limb-onset ALS have a better prognosis than bulbar-onset •Less severe involvement, longer interval between onset and diagnosis, no dyspnea at onset are all associated with better prognosis. •Psychological well-being had significantly longer survival times compared to those with psychological distress.

PD •Bradykinesia - What does it look like?

•Akinesia •Freezing: •Hypokinesia

Statistics

•Alcohol is involved in ¼ injuries •Risks: Risky behavior, joint problems

Autonomic Dysreflexia: seeen in:

•Also known as autonomic hyperreflexia • (above sympathetic splanchnic overflow) • •Seen in both complete and incomplete lesions.The splanchnic nerves are

•Neurogenic regulation cerebral BF

•Alters blood flow by vasodilating vessels in proportion to local function of brain tissue.

Prognosis and Goal Setting

•Always difficult to establish and predict long-term outcomes and set goals for these patients •Factors that help predict outcome after a TBI include: •GCS (initial severity of injury) •Duration of coma Length of PTA

Posterior Cerebral Artery Syndrome***Clinical Manifestations: Temporal lobe ischemia:

•Amnesia

Complications GBS

•Anemia •Respiratory distress •Contractures •Joint dislocation •Anxiety/depression •Cardiac Arrhythmia •Skin breakdown Orthostatic hypotension •Heterotopic ossification •Thromboembolism •Pneumonia •Aspiration •Urinary retention •Paralytic Ileus •Persistent paralysis •Sudden respiratory failure

Balance Retraining Strategies CVA

•Ankle •Hip •Stepping

•Ankle mid swing begins when... ends when...

•Ankle 0o begins as the swinging foot is opposite the stance limb. ends when the swinging limb is forward and the tibia is vertical (ie hip and knee flexion postures are equal)

Ice test MG diagnosis

•Applying ice to weak mm groups leads to improvement in strength of those muscles. Applying ice for 5 min has sensitivity and specificity of 76.9% and 98.3%, respectively. •Acetylcholinesterase is inhibited at the lower temperature.

1.Coma

•Arousal system is not functioning •Eyes are closed, •No auditory/visual function No cognitive or communicative function

Bulbar Clinical Impairments ALS

•As UMNs and LMNs of the bulbar mms degenerate, spastic bulbar palsy or flaccid bulbar palsy develops. ALS - mixed palsy •Dysarthria - impaired speech, common due to weakness of tongue, lip, jaw, larynx, pharynx •Spastic dysarthria: voice sounds forced •Flaccid dysarthria: voice sounds hoarse or breathy •Pharyngeal weakness, air leaks into nose resulting in nasal tone •Eventually speech becomes unintelligible and eventually anarthric (loss of power to articulate speech).

Med team MS

•Neurologist - usually lead •Advanced Practice Professionals (PA, NP) •Nurse - coordination of care, education •Rehab •Physiatrist •PT - Movement, functional mobility •OT - ADLs, IADLs •SLP - communication, cognitive strategies, swallowing •Neuropsychologist - assess and treat cognitive impairments •Mental Health Providers - support, education, depression, anxiety, mood •Urologist •Nutritionist •Pharmacist •Wellness: •Wellness coach •Naturopathic •Personal Trainer Also need standard care - Primary Care Provider, OB/Gyn

Signs and Symptoms PPS: weakness

•New weakness, (leg strength) (slowly progressing) -Fasciculation in muscle -Cramps -Atrophy •Previously affected muscles Previously unaffected muscles Fibrillation only EMG Fascic can see this happening

Medical Management PD

•No Cure, goal is to slow the disease progression and symptomatic treatment of motor features, motor complications and non-motor features •Current medical therapies improve symptoms, but don't slow or halt the disease progression. •EXERCISE - slows for sure! (maybe halts?)

cause and cure MS

•No definitive cause •No cure

High Pressure O2 Delivery

•Non-Invasive Mechanical Ventilation - Continuous Positive Airway Pressure (CPAP) - Bi-level Positive Airway Pressure (Bi-PAP) - Consult MD about patient coming off machine during mobilization.

•STROKE suspected if horizontal spontaneous nystagmus AND ONE or more of the following

•Normal Head Impulse Test (HIT) •Dangerous Oculomotor sign: -Direction changing nystagmus -Positive skew deviation (vertical misalignment)

•BWSTT

•Normal kinematics and phase relationships of the full gait cycle are promoted •Limb loading in midstance •Unweighting and stepping during swing

PD •Tremor - What does it look like?

•Not just hand. Also, jaw, tongue, forearm •Postural tremor, resting tremor •Initial symptom in about 70% of patients •What does this do to/for the patient? •Socially •Functionally Tremor - less severe when relaxed and unoccupied, disappears when sleeping and is reduced with voluntary movement; worsened with emotional stress or fatigue Resting tremor and postural tremor Not intention- that's cerebellar

MS sy's: More Common:

•Numbness/Tingling** •Weakness - Corticospinal lesions • •Gait difficulties 87% •Spasticity, hyper-reflexia •Vision problems - 80-85% •Bowel/bladder problems •Sexual problems •Pain - 55% clinically significant •Emotional Changes •Cognitive Changes - 40-60%

If you have a right paretic lesion:

•Nystagmus (acute spontaneous, positional, afterhead shake) will beat away from the side of lesion (Left beating) •VOR function tests (Head Impulse Testing) will be impaired to the side (corrective saccades when the head is moved to the side of the lesion or right)

Physical Therapy Exam

•Objective testing and follow-up reexamination is important but it can be difficult to differentiate between the progressive course of the disease and the lack of impact of the interventions. •You must weigh the benefits against the psychological impact of repeating tests and measures when the patient is deteriorating. •Remember to focus on areas the patient feels is valuable to them!

Exam CVA •Ambulation and Functional Mobility

•Observational gait analysis (OGA). Examine movements at ankle, foot, knee, hip, pelvis, and trunk.

Ipsilateral pushing (Pusher): •Occurs in •Visual inputs

•Occurs 10% of patients with acute stroke • •Visual inputs remained relatively intact

•Of CVA survivors, _______ will be functionally dependent after _____ year*

•Of survivors, 1/3 will be functionally dependent after 1 year*

•Cauda Equina

•Often incomplete injury due to great number of nerve roots involved and large surface area they encompass Peripheral nerve damage

Communication*

•Often nonaphasic in nature and are related to cognition •Disorganized and tangential oral or written communication •Imprecise language •Word retrieval difficulties Disinhibited and socially inappropriate language *Great difficulty communicating in distractible environment, reading social cues, adjusting communication to meet the demands of the situation

•How does the pt/caregiver perceive the device is working? •Assess:

•Postural alignment (head, shoulders, trunk, pelvis, LEs) •Shirt removed or lifted to nipple line 1. Can alignment be corrected with gentle pressure? 2. What factors may be interfering with good postural alignment? **ask pt to transfer onto a mat table. Note the transfer method used and level of assist. Then don't create a new system that interferes with their function

Integumentary/Sensory GBS: Wide range of sensory changes (anaesthesia to hyperaesthesia)

•Potential changes in vibration and position sense •Pain, numbness, tingling •Hyperaesthesia - various textures, surfaces . build a bed tent or wrap legs to ↓stimuli

Sitting/Bridging CVA

•Practice scooting in sitting •Practice sit<>transitions •Bridging •May help stabilize the foot

Mat table measurement: Supine:

•Preliminary linear measurements (thigh and calf length, trunk and hip width) •Check all appropriate joints (UEs, LEs, head/neck/trunk/pelvis) •ROM (in supine and sitting) 1.Hip flexion (knees flexed) 2. 3.Ankle dorsiflexion Spasticity/tone (in supine and sitting)

GBS •Presents ___ to ___weeks following benign respiratory or GI illness

•Presents 2-4 weeks following benign respiratory or GI illness.

Postpolio Syndrome (PPS)

•Presents in pt's with a previous history of acute poliomyelitis •Combination of primary and secondary impairments➝ functional limitations and disability •

•Air

•Pressure relieving •Less stable transfers/posture •More maintenance

PT Focus TBI: Primary goal:

•Prevent secondary complications from prolonged bedrest/ immobilization •Begin early mobilization when medically cleared •Initiate patient and family education Prevent contractures, atrophy, pressure sores Dec atrophy, dec pressure sores, contracture, start educating families bs pts us not in pos to lay down new memories

PT examination and acute treatment: •Rancho I, II, III

•Preventing Secondary Impairments* •Improving Arousal Through Sensory Stimulation** •Managing effects of Abnormal tone and spasticity •Early transition to sitting postures

Medical Management infections

•Primarily symptomatic •Pharmacological interventions are available for some viral infections (Herpes encephalitis) •Aggressive management of increased intracranial pressure may be necessary

•What systems does it affect? PD

•Primary and secondary effects can be seen in nearly all body systems.

Pharmacology Primary Dopaminergic/Dopamine replacement: •Levodopa/Carbidopa: Sinemet®

•Primary benefit alleviating BRADYKINESIA and RIGIDITY (less on tremor, none of instability); "on-off" periods, dyskinesias (if see v long off or v bad dyskinesia talk to MD)

Postural Control and Balance*** CVA

•Problems reacting to an external force or self-initiated movements

gbs •May continue to progresses from ________ to __________

•Progresses from days to weeks

gbs •Progressive - ___________ weakness and sensory changes occur over ______ to _____.

•Progressive - symmetric ascending weakness and sensory changes over hours to days

Pathophysiology ALS

•Progressive degeneration and loss of motor neurons in the spinal cord, brainstem and motor cortex. •UMNs in cortex are affected •Corticospinal tracts are affected •Brainstem nuclei that are affected: •CN V-trigeminal •CN VII-facial •CN IX-glossopharyngeal •CN X- vagus •CN XII-hypoglossal •Massive loss of the anterior horn cells of spinal cord result in muscle atrophy and weakness Can spread to LMN UMN in cortex, CS tracts affected, BS affected Oculomotor mm's generally spared but can affect... Can have sensory loss, its just rare Occuluomotor and control BB usually spared

GBS •Diagnostic criteria

•Progressive weakness and areflexia (ascending, •Sensory involvement •Cranial nerve involvement •Autonomic dysfunction •Absence of fever

Types of MS - SPMS

•Progressive worsening over time •Can also be characterized as with/without progression (evidence of disability accumulation over time, with or without relapses) If untreated with disease modifying drugs, 50% transition within 15 years, 90% in 25 yrs. Can be active or inactive - can be with or without progression

•Phases GBS

•Progressive: 2-4 wks •Plateau: variable •Recovery: 6-12 mos with 2-3 yrs for complete

TBI •Secondary Impairments are due to:

•Prolonged immobility •Concomitant injury

Ultimately.... ALS

•Promote independence •Maximize function •Focus on health and wellness early on •Provide alternative ways to achieve functional tasks •Minimize secondary effects •Educate and support patients and their care givers •Refer out/identify red flags early

Therapeutic positions CVA

•Prone on elbows/modified prone on elbows (table top weight bearing) •Side-sitting • •Tall-Kneeling and half-kneeling

• standing cva

•Proper symmetry and alignment is your goal Practice standing with unilateral UE support (more affected side) and then free standing (No UE support). First hold posture Then moving in the posture And finally withstanding challenges to dynamic balance.

hand controls

•Proportional

Altered Coordination CVA

•Proprioceptive losses can result in sensory ataxia •Basal ganglia involvement may lead to slow mvmts (bradykinesia) or involuntary mvmts (choreoathetosis, hemiballismus)

Rear-Wheel Drive: positives

•See exactly where they are going and are able to watch their feet •Drive straight at high speeds •Smooth ride due to shock system

Complications/Indirect Impairments: Neurological CVA

•Seizures •Hydrocephalus

CVA •Muscle composition changes:

•Selective loss of type II fast-twitch fibers •Increase in the percentage of type I fibers (consistent with aging) •This selective type II loss = slowed force production, difficulty with initiation and production of rapid, high-force movements, and rapid onset of fatigue.

sci Selective stretching and Tone

•Selective stretching •Tone and Reflex integrity. What would you expect? HS, long finger flexors (things we DON'T stretch)- can stretch finger flexors IF wrist flexed, but NEVER is wrist extended •- no reflexes or tone (dn mean no sens or motor lowest sacral)

•Fall Risk: CVA

•Sensorimotor deficits • •Confusion •Attention deficits •Perceptual deficits •Visual impairments •Behavioral impulsivity •Depression •Communication problems

Psychological acute

•Sensory deprivation (ICU psychosis/delirium) • decreased attention span, awareness •Depression, labiality, anxiety •Sleep disturbance •Increased auditory threshold •Decreased pain threshold

Sensory Awareness/Recovery

•Sensory stimulation is important for recovery •Repeated sensory stimuli stimulates tactile, mechano and muscle receptors --> Stroking, stretch, superficial and deep pressure, approximation, electrical stimulation, weight bearing, brushing, icing, vibrating •Functional activities that encourage bilateral use of UE

Spared Functions ALS

•Sensory system and spinocerebellar tracts •Brainstem nuclei for cranial nerves controlling external ocular muscles - CN III-oculomotor - CN IV-trochlear - CN VI-abducens •If degeneration occurs, especially in external ocular muscles, it does so late in the course of the disease. •Motor neurons of the Onufrowicz nucleus (Onuf's nucleus) is a distinct group of neurons located in the anterior horn of the sacral region of the spinal cord involved in the maintenance of continence. (control of pelvic floor, anal and external urethral sphincters)

•Contractures and skin breakdown: positioning, bracing

•Serial Casting: •Plantar flexors or bicep contractures

GBS •Severest point or the "_________". What percent reach the lowest point at 1 week _________- 3 weeks __________.

•Severest point (nadir) -1 week (50%) - 3 weeks (80%) •Plateau of persistent unchanging symptoms

Pulmonary issues GBS

•Severity of dysfunction on a wide continuum •May have trach with mask to deliver O2 •Need to work with team on airway mgmt •Work in upright postures, increasing time out of bed (chair, w/c) •Assist with secretion mgmt - cough assist •Be aware of suction needs and methods •Monitor O2 sats and RR during activity •Breathing exercises, postural drainage, incentive spirometry •Be aware of aspiration risk

Poor prognostic factors GBS

•Severity of muscle weakness (tetraparesis) •Need for respiratory support •CN involvement •Bulbar dysfunction •Autonomic dysfunction •Length of time to nadir (Rapid onset to peak) •Axonal damage •Persistent weakness •Age>60 years •Pulmonary infections

Phase 2. Loading Response Objectives

•Shock absorption •Controlled weight transfer to stance limb •Preservation of progression

Management of Shoulder Pain CVA

•Shoulder impingement syndrome •Adhesive capsulitis - Poor handling and position of the more affected UE have been implicated in producing joint microtrauma and pain.

sci rom

•Shoulder, hamstring, ankle especially

•Task-oriented training

•Significant and large improvement in motor function

•Early Mobility (1-3 rancho)

•Sitting position and out of bed to w/c •Head supported, midline orientation if possible •Tilt table •Reclining wheelchair ALSO: Positioning, stretching/ROM

Integumentary System acute

•Skin Breakdown •Pressure ulcers •Risks: positioning, decreased tissue mass, poor skin care/incontinence, shear •Sites: sacrum, heels, ischium, occiput, trochanter •Poor skin turgor (elasticity) •Edema - may predispose to cellulitis •Subcutaneous bursitis (due to pressure)

Indirect impairments TBI

•Skin breakdown, decubitus ulcer •DVT • •Decreased bone density •Muscle atrophy •Decreased endurance •Infection Pneumonia

MS and **Cooling!!!

•Slight elevations in core temp can cause temporary symptom worsening in 70-80% of people with MS, to varying degrees •Exercise in cool environment •Cool the patient: • •During • •Cooling vest, other cooling apparel •After • •Drink cold water •About 20% can have cold sensitivities, as well

•Paretic Lesion

•Slow drifts to the side of the lesion with corrective jerks to the uninvolved side •Example: Inner ear infection (neuritis/ labyrinthitis), Meniere's disease after "ear is dead"*

DVT's**** cause

•Slow flow of blood allows higher concentrations of procoagulants (thrombin) to develop in localized areas •Normally procoagulants rapidly mix with large quantities of blood and are removed from liver

•Typical gait: CVA

•Slow gait •Reduced stance time on impaired leg •Increased step length relative to less-affected side •Decreased push-off Lack of dissociating right and left side of body

•Irritative Lesion

•Slow push to opposite side with jerk to the involved side •Example: BPPV, Meniere's disease in acute state*

MS sy's Tertiary:

•Social issues •Employment issues •Psychological issues

•Electrolytes •Sodium (Na): < ____ mEq/L - may cause impaired cognition, monitor vitals for hypotension •Potassium (K): < ___ or > __ mEq/L - may cause muscle weakness, cardiac issues •Calcium (Ca): < __ or > ____ mg/dL - may cause muscle weakness or cramps, impaired cognition •Magnesium (Mg): < ____ or >____ mEq/L - may cause weakness, tremors, seizure or hypotension •Phosphate (PO4): < ____ or >___ mg/dL - may cause dysrhythmia, weakness, agitation, cramping

•Sodium (Na): < 130 mEq/L - may cause impaired cognition, monitor vitals for hypotension •Potassium (K): < 2.5 or > 5 mEq/L - may cause muscle weakness, cardiac issues •Calcium (Ca): < 6 or > 13 mg/dL - may cause muscle weakness or cramps, impaired cognition •Magnesium (Mg): < 1.0 or > 9.0 mEq/L - may cause weakness, tremors, seizure or hypotension •Phosphate (PO4): < 1.0 or >9.0 mg/dL - may cause dysrhythmia, weakness, agitation, cramping

Exercise and ALS

•Some discourage ex programs because of the fear of overuse weakness. Not a lot of research exists for these patients. •It is documented for other neuromuscular diseases that exercise programs are beneficial and do not produce overuse weakness: --> Overuse weakness does not occur in mm with a MMT grade 3/5 or better --> Moderate resistance ex can increase strength in a mm with MMT grade of 3 or greater --> Strength gains are proportional to the initial mm strength --> Heavy eccentric exercise should be avoided --> Ex may produce functional benefits

Exercise and Exacerbations MS

•Sometimes, new or old symptoms will start while exercising - this is just temporary - NOT an exacerbation! (termed pseudo-exacerbation) •Reduce intensity •Should recover within 1 hour • •Pseudo-exacerbations should resolve in 24 hours

•SpO2

•SpO2 > 88%

variety of impairments that affect gait in MS

•Spasticity - up to 80%, LEs mostly •Coordination/Motor Control - synergies, cerebellar pathway demyelination •Weakness - limbs AND trunk •ROM limitations •Sensory Changes •Loss of Balance •Fatigue

Research humans: PD: exercise improves function in wide range of arenas •Specific - •Forced exercise at _____ is better than _____ exercise (_____ intensities) as far as function •Learning (motor or other) improves _____ and _____ function (mood, arousal, etc.) •____ activities (_____) improve gait characteristics •_______ (forced pace of 80-90 rpm) improves ____, ___, ___, _____

•Specific - if train balance, balance improves; train strength, strength improves; training balance doesn't necessarily decrease falls- Level 1A •Forced exercise at high intensities is better than voluntary exercise (lower intensities) as far as function - Level 1B •Learning (motor or other) improves cognition and frontal lobe function (mood, arousal, etc.) - Level 2A •Rhythmic activities (dance, metronomes) improve gait characteristics •Tandem cycling (forced pace of 80-90 rpm) improves balance, cardiopulmonary, fatigue, cognition - Level 1A

•Rx should include: PPS

•Specific mm groups to include •Specific mm groups to exclude •Exercise mode, frequency and duration; REST BREAKS!!!

•Sitting CVA: •Focus on achieving a symmetrical posture with proper:

•Spine alignment •Pelvic alignment •Feet flat on floor

Nystagmus Observation/Vestibular Testing

•Spontaneous nystagmus (with and without Frenzel's) •Gaze-evoked •BPPV Provacative testing (Positional) - Dix Hallpike Test - Sidelying Test - Roll test •HIT •After head shake •Motion sensitivity testing •DVA

•Foam

•Stable for transfers/posture

Motor Planning** PD

•Start hesitation: mvmt preparation is significantly prolonged •Difficulty performing complex, sequential or simultaneous mvmts - What does that sound like? [multi-step commands, distractions, dual tasking] •Micrographia: abnormally small and cramped handwriting and/or progression to abnormally small handwriting that is difficult to read. [they can write bigger, but it takes so much concentration that they have trouble with the content of their writing]

Abnormal Reflexes in CVA

•Stretch reflexes are hyperactive •Patients may demonstrate: (consistent with UMN syndrome) • •Clasp-knife response

Stretching PPS

•Stretching - be careful to consider selective tightness • •Perform with both stable (unless painful) and unstable (mild intensity) mm

Spasticity/Stiffness- Rehab MS: •Interventions

•Stretching program •Cooling •Bracing/positioning/Standing frame •Environmental Modifications •Other Tone Reducing Techniques: Pool, NMES...

Anterior Cerebral Artery Syndrome

•Supplies: •(frontal and parietal) •Subcortical structures -Basal Ganglia -Anterior fornix -Anterior 4/5 of the corpus callosum •Problems apraxia (corpus callosum)

Posterior Cerebral Artery Syndrome

•Supplies: •Medial and interior temporal lobe •Upper brainstem •Midbrain •Posterior diencephalon

Postural support system

•Surfaces that contact the user's body directly •Foot supports* •Head support •Lateral supports •UE support •Straps

•Aerobic exercise (sub max level) ALS

•Swimming •Walking •Biking Also: ROM and stretching

PD •What does it look like?

•Symptoms develop slowly over years, typically. non-motor symptoms are often more limiting, including: apathy, depression, constipation, sleep behavior disorders (act out their dreams), loss of smell, and cognitive impairment

Hypoxic-Ischemic Injury (HII)

•Systemic hypotension •Damage to specific vascular territories of the brain •Global damage and associated with poorer cognitive function and lower expected outcomes

•Dysphagia CVA

•TPN 51% have swallow difficulties. Oral stage: CN V, VII; the pharyngeal stage: IX X, XI, or oral and pharyngeal: XII delayed triggering of the swallowing reflex, reduced pharyngeal peristalsis and reduced lingual control. Complications of Aspiration: respiratory distress within hours, aspiration pneumonia, death. Also dehydration and compromised nutrition

Poor Balance/Fall Risk - Interventions

•Tai Chi, Yoga, Pilates, Core strengthening •Manipulate somatosensory input •Vestibular exercises •Pool therapy in cool water (<85֯) •Add Cognitive challenges •Gait training •Cooling •AD assessment (including footwear and timing of use) •If cerebellar: Weighted vests, boots, walker, utensils, etc. Near fallers and fallers perform similarly on timed walking tests!

Surgical management PD: Deep Brain Stimulation

•Thalamic - tremor •Globus Pallidus - all ***Subthalamic nucleus- us reduce amt of meds needed after surg* •Most common

Center/Mid-Wheel drive: n

•The "hardest" ride due to smaller casters • •Less stable at high speeds •Must know what is behind and in front of chair when turning

Risk vs Benefit Considerations of Therapeutic Intervention

•The continuum of risk is a parabolic curve

Signs and Symptoms other pps

•Fatigue - late afternoon/early evening, sudden and total wipeout -->Aerobic capacity •Muscle pain/joint pain •Cold intolerance •Progressive respiratory and bulbar difficulties (usually in individuals who had them in acute polio) •Sleep apnea- even without the obesity sleep that inc risk sleep apnea in all of us Fatigue: not all day, not at time of activity, recovery does not occur with typical rest periods; sometimes headaches and sweating - autonomic overload? Weakness: primarily in repetitive and stabilizing contractions, not single maximum effort Bulbar: in those with kyphosis or scoliosis

PPS symptoms

•Fatigue and exhaustion with minimal activity, weakness, mm and jt pain, sleep disorders, intolerance of cold (LE>UE)

MS sy's

•Fatigue, visual disturbance, loss of balance, impaired coordination, dysarthria, tremors, numbness, memory/concentration deficits, bowel and bladder issues, and more

•Tubes

•Feeding •Chest •Vac •Suction

MS gender

•Females: 2:1 vs. 3:1

Ewald's Laws

•First: eye/head movement occur in the plane of the canal being stimulated -movement horizontal, produces a horizontal eye motion -motion horizontal right--excites right HC--horizontal left slow eye mvmt (right beating nystagmus) 2nd: Excitatory is more effective than inhibitory

Signs and Symptoms - AIDP: Motor dysfunction

•Flaccid paralysis/paresis •Severe cases see mm wasting in 2 weeks •Absent DTR's (hallmark sign)

Factors influencing postural alignment

•Flexible deformity •Correctable with effects of gravity eliminated •Fixed deformity •Not correctable when gravity is reduced •Accommodation is required

•Hybrid/honeycomb:

•Foam/air •May be able to find a good balance

Rear-Wheel Drive: Negatives

•Footrests angled forward to clear larger front casters •Least stable, tippy** •Largest turning radius

•Skin Care sci

•Forward lean 45 degrees •Tilt: 65 degrees •Maintained at least 2 minutes •Skin inspected routinely

Management TBI

•Fractures, neurological problems •Genitourinary problems •Respiratory problems •Cardiovascular problems •Dermatological problems •Post traumatic seizures •Ventricular dilation •Impaired liver function tests •Hypertension •Decubitus ulcers

Secondary/Metastatic Brain Tumors: Specific Signs and Symptoms

•Frontal •Parietal •Occipital •Temporal •Cerebellar •Brain Stem Pituitary

What else does dopamine do? •Frontal cortex •Limbic system •Autonomic nervous system

•Frontal cortex: •Attention- gen RAS, but also some fxns here •Limbic system: •Rewards, addiction centers •Arousal •Mood management •Autonomic nervous system: •Increased HR and cardiac contractility •Vasodilates •Increases sodium excretion and urine output •Reduces insulin production •Decrease nausea

•______ when affected can produce a number of emotional changes (CVA)

•Frontal lobe, hypothalamus, and limbic system when affected can produce a number of emotional changes

Brunstrom•Stage Three- eval method

•Full UE synergy; hip, knee, and ankle flexion are coupled in either sitting or standing. •Ashworth 3-4maybe grasp ball, but go to throw and hand never releases

General Goals for MOD/SEVERE TBI in Acute

•Function and alertness increased •Reduce risk of secondary impairments** (identify some, then tx) •Motor control improved •Tone managed •Postural control improved •Tolerance of activities and positions improved •Joint integrity and mobility improved or remain functional •Family/caregiver education Care is coordinated

Gait MS: •Gait deficits affect ____% and can be from a variety of impairments

•Gait deficits affect 87% and can be from a variety of impairments

PT Evaluation: •Goals: MS

•Gait/functional mobility is PRIORITY •Promote independence, safety, function •Prevent complications - deconditioning, weakness, contractures •Include family/caregivers in goals

Gait - Rehab:•MS: •Interventions

•Gait/locomotor training •Cooling •Comprehensive program - •Behavior/environmental mod •AD/powered mobility assessment

•Subjective PPS

•General medical hx and medications -original effects, devices/braces used during initial recovery, level of function after recovery -Hx of PPS: date of symptom onset, formal medical eval/dx, previous tx for PPS

Alterations in Tone: flaccidity (CVA)

•Generally short-lived (lasts a few days or weeks) •It may persist in small % of pt's with lesions restricted to the primary motor cortex or cerebellum

Dyskinesias/Dystonias PD: •Generally, •Dyskinesias more common in individuals with

•Generally, side-effect of medications •Dyskinesias more common in individuals with •Younger onset •Earlier or very late initiation of dopamine replacement therapies •Higher daily dose equivalents of dopamine replacement •Akinetic-rigid phenotype

•Cultural Considerations:

•Genetic heterogeneity changes reactivity of cells to probes and antibodies used in tests. This may result in false-negative lab findings. •Genetic variability will become an increasingly more important consideration in the future. •Food preferences may lead to differences in norms as well.

Etiology = Combination: PD: Increased risk

•Genetics - 10-15% •Individual Factors -Age = Largest risk factor -Gender - Males •Environmental Factors -Head injury -Area of residence -Occupation -Pesticide exposure -Heavy metal exposure -Solvents -•Tricholoroethylene

HO maintenence

•Gentle maintenance of ROM •Surgery when extreme limitations in function impede rehab and independence, only once bone is mature at about 1 year.

•Endocrine •Glucose: < ___or >____mg/dL - may cause decreased activity tolerance

•Glucose: < 70 or >200 mg/dL - may cause decreased activity tolerance

Spastic Hypertonia* SCI timeline

•Gradual increase first 6 months •Plateau reached 1 year

Encephalitis

•Group of diseases characterized by inflammation of the parenchyma of the brain and surrounding meninges. •Variety of agents, usually a viral invasion of the cells of the brain and spinal cord. •Different cell populations vary in their susceptibility to infection by a specific virus. •Acute encephalitis

•Sitting CVA:UE/UE's can help

•Hands on mat (hemi side supported at hand/wrist/elbow) •Hands on table, swiss ball •Hands on therapist's shoulders (therapist sitting in front of patient and supporting impaired hand/arm)

3.Vestibular-Ocular Reflex Cancellation (VORc)

•Head/object moving in phase

Encephalitis- 5 Pathological Syndromes: Acute viral

•Herpes simplex encephalitis •St Louis Encephalitis •West Nile Virus •Western Equine Encephalitis

Functional Mobility Training GBS

•Incorporate activities throughout - can break down tasks to work on strength, balance, endurance, etc •Safety - balance, sensory dysfunction •Bed mobility •Transfers •Balance - sitting, standing, gait •WC propulsion/management •Gait training •ICU or acute. What interventions? All thise skills just like toehrs, just slower conserve pace

MG rehab

•Increase function, exercise with frequent bouts of rest

CV acute: HR response to submaximal exercise

•Increased

Phase 6. Initial Swing

•Increased knee flexion, lifts foot for toe clearance •Hip flexion advances the limb •Hip 15o flexion •Ankle 5o PF

•Theories PPS etiology NERVE:

•Increased metabolic demand on giant motor units, with loss of individual motor units

Community Walker

•Ind Walking home and all community activities • and uneven terrain •>7,500 steps/day • •6MWT >287 meters

Limited Community Walker

•Ind. enter/leaving home •Ind. Up/down curb • •Ind walking moderate community settings •2,500-7,499 steps/day • •6MWT 205-287 meters

Symptoms of weakness

•Inefficient patterns of muscle activation •Difficulty maintaining a constant level of force production •c/o feeling weakness •Reaction times are increased •Timing disorder that limits force production during voluntary movements **if coactivation occurs there is increased energy used, greater levels of fatigue

Meningitis:

•Infection spread through the CSF •Inflammatory process involves the pia, arachnoid, subarachnoid space, and adjacent superficial tissues of the brain and spinal cord. •CSF can be contaminated by a penetrating wound caused by trauma or medical procedures, implantation of ventriculoperitoneal (VP) shunt

Neurological sequelae

•The diversity of neurological sequelae that may occur after an inflammatory disorder in the brain (brain abscess, encephalitis, or meningitis, etc.) provides a range of challenges to the rehabilitation team. •As the PT you must identify the problems underlying the individual's movement disorder. Not a typical pattern... •Physical, cognitive and psychological impairments •Ultimate goal: return home

ALS Framework for Rehab

•The goal should be to maintain his or her independence and function for as long as possible •You not only address an individual's current problems, but also plan ahead for future problems. •Family/caregiver's must be a cornerstone of treatment.

Provide the Minimum Support Necessary to Achieve Anticipated Goals and Expected Outcomes

•The least restrictive supports required to facilitate the acquisition of new skills and foster independence rather than create unnecessary dependence on equipment. •Especially important in the younger people as they grow and mature

Pathophysiology: •The progression of ALS is thought to spread in a contiguous manner, within spinal cord segments (_______) before developing ________ symptoms. •_______ spread within the spinal cord and spread from the _____ to _____ region appears to occur faster than ______ spread within the SC.

•The progression of ALS is thought to spread in a contiguous manner, within spinal cord segments (Cervical to cervical) before developing rostral or caudal symptoms. •Caudal-to-rostral spread within the spinal cord and spread from the cervical to bulbar region appears to occur faster than rostral-to-caudal spread within the SC.

Symptoms of Meningitis

•The symptoms of meningitis are likely to include a very high fever, severe headache, sleepiness, altered consciousness, seizures (kids), nuchal rigidity, difficulty waking up, vomiting or nausea accompanied by a headache, confusion, difficulty concentrating, difficulty maintaining eye contact (especially in the very young), loss of appetite, lack of thirst, sensitivity to light, and in some types of meningitis, a rash.

•All studies suggest: CVA

•There is no one intervention optimal for all patients with stroke •You need a BIGGER BAG OF TRICKS

•Objectives: Phase 6. Initial Swing

•Thigh advances forward •Knee flexion to achieve toe clearance

Who is at the Greatest Risk? infections brain

•Those with common infections: Common infection can compromise the protective barriers of the CNS. •Immuno-deficient -Chronic corticosteroid use -Immunosuppressant use -Cytotoxic (chemotherapy) drug use •Antibody deficient •Those who are very young •Those who are elderly -the frequency AND severity is typically greater.

Medical Marijuana PD

•Though much interest and several clinical studies, no demonstration that cannabis can directly benefit people with PD Maybe some improvement with anxiety, pain, sleep dysfunction, weight loss and nausea Impaired cognition, dizziness, blurred vision, mood and behavioral changes, loss of balance, and hallucinations Chronic use increases risk of mood disorders and lung cancer

Pulmonary Artery (PA) Catheter aka "Swan Ganz Catheter"

•Threaded through the heart into the Pulmonary Artery •Obtains hemodynamic info unobtainable by other IV lines •OK to mobilize; requires additional person to manage lines Cautious with amount of activity with them

•Maintaining ROM and proper positioning is important in CVA: •Hip, knee, ankle:

•Tilt table •Standing frame

•Gait - speed, endurance, stability, safety MS

•Timed 25' Walk Test vs. 10m Walk Test •12 Item MS Walking Scale, TUG/TUGc

Sensory Stimulation TBI

•To increase arousal and elicit mvmt •Multisensory manner (stimulation and rest balanced), the RAS may be stimulated= general increase in arousal •Sensory systems systematically stimulated:

Clinical Picture for Inflammatory Disease: Acute phase:

•Inflammatory process may result in impairments in arousal and attention. •Range from nonresponsive to agitated •Impaired affect --> Hypersensitivity, impaired affect --> Exaggerated emotional responses •May have distortion in memory or perception of events. •After acute brain inflammation subsides you may begin to see generalized or focal brain damage. •Every patient will present differently hard to paint a clear clinical picture.

Cardiovascular GBS

•Influenced by autonomic system - ↑resting HR, unstable BP •Risk for DVT •Poor functional endurance and mm endurance (REST!) •Work on vertical tolerance -Raise HOB -Reclining w/c -Progressive sitting -Tilt table, standing frame -Pressure garments, ace wraps, abdominal binder

Infections •Medical Management

•Initiation of the antimicrobial regimen and symptom management.

TBI Focal Injury

•Injury is localized to the area of the brain under the site of impact on the skull •Hematoma •Edema •Contusion •Laceration (or a combo of the 4) •Coup-contrecoup injury

Fam ed serial casting

•Instructions for routine monitoring for pain, skin condition •Instructions for monitoring condition of the cast • •Instructions for contacting therapist to ask questions or report concerns

PT examination TBI

•Integument integrity •Ventilation and respiratory gas/exchange • •Sit on side of the bed with assistance •Transferred into w/c (reclining/tilt-in-space)

Edrophonium Test/Tensilon test MG diagnosis

•Intravenous administration of edrophonium chloride (Tensilon-drug that blocks breakdown of acetylcholine by cholinesterase "acetylcholinesterase inhibitor") and temporarily increase the levels of acetylcholine at the NMJ)

Vestibular NYSTAGMUS

•Jerk nystagmus •slow phase: vestibular driven •fast phase: central "reset"---that is what we see

Phase 4. Terminal Stance: knee and ankle and objectives

•Knee 5o flexion •Ankle 10o DF •Objectives •Dynamic stability over the forefoot Knee completes extension (then begins a new arc of flexion Increased hip extension and heel rise put the limb in a more trailing position.

Management of Shoulder Pain: •Causes of HSP:

•Lack of tone •Mm paralysis (reduce support and normal seating action of rotator cuff) •Ligaments and capsule become shoulder's sole support

Scapula in HSP

•Lacking supportive musculature, the scapula downwardly rotates and depresses; --> the sublux

Wheel options (manual): •Wheel size (identify positives and negatives)

•Larger (26-large vs. 24-standard) •Smaller (20 inch for foot propellers and short in stature) •Knobby (outdoors but tear up carpet); mountain bike •High-pressure (low friction but slick on ice/ramps)- look like 10 speed wheels- concrete jungle

relapses Last from (MS)

•Last from a few days to weeks or months

Types of MS - CIS

•Lasts at least 24 hours •Caused by inflammation or demyelination in CNS •(60-80% eventually developed MS with prior criteria) Medications are available to treat this now!

Secondary Support surfaces

•Lateral trunk supports •Medial (pommel) and lateral knee supports •Lateral thigh supports •Anterior chest supports •Headrest • • • •Consider transfer

•The degree of motor recovery depends on: (CVA)

•Lesion location •Lesion severity •Capacity for adaptation through training

Pathophysiology MS

•Lesion size/quantity indicates severity and progression •Each lesion doesn't necessarily directly relate to patient symptoms

Fracture stabilization: Immobilization:

•Tongs. In supine, weights attached via pully to screws in skull. Temporary traction prior to halo. •Halo >SOMI (sterno-occipital-mandibular immobilizer) •Turning frames and beds (stryker frame, rolo rest) •TLSO

Pathophysiology ALS: •As motor neurons degenerate, they _____ •Healthy, intact surrounding axons can _____ •This can preserve _____ and ______ early in the disease •Re-innervation can compensate for the progressive degeneration until motor unit loss is about ___%. •As the disease progresses _______

•As motor neurons degenerate, they can no longer control the mm fibers they innervate. •Healthy, intact surrounding axons can sprout and re-innervate the partially denervated muscle. •This can preserve strength and function early in the disease •Re-innervation can compensate for the progressive degeneration until motor unit loss is about 50%. •As the disease progresses re-innervation cannot compensate for the rate of degeneration.

s/s MG

•Asymmetrical ptosis, diplopia, unstable/waddling gait, weakness (arms, hands, fingers, leg, neck), change in facial expression, dysarthria, shortness of breath and dysphagia

MG what is it

•Autoimmune neuromuscular disease •Fluctuating muscle weakness of voluntary muscle groups and fatigue •A reduction (up to 80%) in the receptor sites for acetylcholine at the neuromuscular junction results in decreased or absent muscle contraction •This reduction in the number of receptor sites is caused by circulating antibodies that destroys and/or blocks the acetylcholine receptor sites at the postsynaptic neuromuscular junction. --> It is unclear why these antibodies are attacking the body.

Phase 2. Loading Response

•B.W. transferred onto forward limb •Using heel as rocker, knee is flexed for shock absorption •Brief arc of PF interrupts heel impact

Therapist Flexibility! MS

•Be realistic with expectations •Know that there will be bad days •Have options for home program (and clinic activities) •Be as flexible as possible with clinic schedule •Help your patient be honest with themselves

Head Impulse Testing

•Bedside Test to detect loss of vestibular or inner ear function •Hold patient's head firmly and then with quick impulse turn the head <10 degrees •Observe any (even) momentary loss of visual fixation •Suggests declined inner ear capacity to that side •Can be unilateral or bilateral

Examination- function- Postural Control and Balance (StrokeEDGE) CVA

•Berg (BBS) •Fugl-Meyer Assessment (FMA) •Functional Reach Test •Performance-Oriented Mobility Assessment—Tinnetti (POMA) •Timed Up and Go Test •Clinical Test of Sensory Interaction and Balance (CTSIB) •AM-PAC "6 Clicks"**

•Medications can alter cardiac response: •Beta Blocker- •Diuretics - •Vasodilators -

•Beta Blocker- with lower peak heart rates •Diuretics - reduced fluid volume, electrolyte imbalance, dysrhythmias •Vasodilators - cd to prevent hypotension [If dizziness BS stroke and nystagmus not nearly a red flag as if orthostatic related. Sit to stand or change in position orthostatic- do BP- have to meas bp sitting to know if sig lower enough to be orthostatic.]

•Subarachnoid Hemorrhage (SAH)

•Bleeding into the subarachnoid space typically from an aneurysm (affecting LARGE blood vessels)

Diagnosis of Bacterial Meningitis

•Blood cultures •Sample of CSF - By lumbar puncture - CSF pressure is consistently elevated - CSF sample reveals --> Increased protein count --> Decreased glucose

Vegetative state:

•Brainstem manages cardiac, respiratory and other vegetative functions, •Eyes may be open though awareness is absent •Reflex smiling/crying may be present •Withdraw to noxious stim but no purposeful movements

Early Warning Signs- can also include:

•Brief loss of consciousness (fainting, confusion, convulsion, coma) •"HA-with increased blood pressure

Exacerbating Factors MG

•Bright sunlight •Surgery •Immunization •Emotional stress •Menstruation •Illness (eg, viral infection) •Certain medications (eg, aminoglycosides, ciprofloxacin, chloroquine, procaine, lithium, phenytoin, beta-blockers, procainamide, statins)

•Post-Acute Phase CVA Inpatient rehabilitation (certified by

•CARF and JCAHO)

Secondary cell death in secondary injury

•Chain of cellular events following TISSUE DAMAGE and secondary effects of hypoxemia, hypotension, ischemia, edema, ELEVATED ICP (glutamate neurotoxicity, influx of calcium, free radicals, cytokines, inflammation>>cell death)

It can't be..... (nystagmus)

•Change direction with change in gaze •Change directions in one position •Be severely intense without subjective complaints of vertigo ...If it is coming from the peripheral vestibular system.

Cerebral Blood Flow

•Changes in blood viscosity •Changes in intracranial pressures •Changes in blood pressure (next slide) •Neurogenic regulation •Released metabolites

brain tumors typically occurs in

•Children 0-15 year old •Adults 40-60 years old •Males > Females •White Americans > Black Americans

Clinical Presentation GBS: Age: Onset: Ventilation? Sy x3 how many die of secondary

•Children or adults •Rapid onset of ascending weakness or paralysis (mild - severe) •LE's -> trunk -> face (may require ventilation ~20%) •Pain •40 - 85% have severe fatigue •Sensory changes - stocking glove in nature •Secondary complications (~5% die)

Other variant forms GBS

•Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) •Acute motor sensory axonal neuropathy (AMSAN) •Acute panautonomic neuropathy Bickerstaff's brainstem encephalitis (BBE)

Key Examination Areas ALS

•Cognition •Psychological status •Pain •ROM/Joint integrity •Strength •Tone •Cranial nerve integrity •Posture/postural control •Balance •Gait •Respiratory function •Skin integrity •Current and future living environment •Fatigue •FUNCTIONAL STATUS!

•Diagnosis PPS

•Confirmed history of previous polio (now by EMG) •Partial to complete muscle strength loss followed by recovery •Stable course for at least 10 years •Gradual onset of progressive and persistent new mm weakness or fatiguability, persisting for 1 yr or more

PT exam and intervention rancho 4

•Consistency •EEXPECT NO CARRYOVER •Model calm behavior •Expect egocentricity •Flexibility/options •SAFETY

•Goals: Choose which programs to run and which to inhibit - semi-conscious problem solving (PD)

•Control kinetic activity, muscle tone, muscle force •Contributes to automaticity •Awareness of body orientation, adapt behavior to changing task requirements, motivation

•Cortical strokes, may _____walk •Patient's with sensory deficits

•Cortical strokes, may regain the ability to walk. Patient's with limited recovery who lack voluntary isolated control can be trained •Patient's with sensory deficits can relearn how to walk

Anxiety and Depression ALS

•Counseling as well as medications are appropriate for both patient and the family •Remember that medication may not take affect for several weeks •SSRI (Prozac, Zoloft) for depression. Side effect insomnia/agitation •Tricyclic antidepressant (Elavil, Tofranil) for depression with insomnia or agitation. •Benzodiazepines (librium, diazepam) for anxiety with depression and insomnia

Encephalitis- 5 Pathological Syndromes: Progressive viral encephalitis "Slow virus" encephalitis

•Creutzfeldt-Jakob Disease (CJD) •Kuru

PD: •_____ learning is usually intact •Difficulty with ______

•Declarative learning is usually intact •Difficulty with generalization of tasks/skills

VO2 max

•Decreased

cardiac size/volume

•Decreased

left ventricular end diastolic volume

•Decreased

stroke volume

•Decreased

Gastrointestinal System acute

•Decreased fluid intake, appetite •Increased transit time in esophagus, stomach •Reduced small bowel motility (2nd to increased adrenergic activity) •Constipation

Indications to discontinue (even without achieving goal)

•Decreased skin integrity • •Allergic reaction • •Decreased tolerance • •Decreased safety

Signs of ↑ Intracranial Pressure

•Decreasing level of consciousness (stupor and coma) •Vomiting •Unreacting pupils (CN III signs)

MS •Tests and measures

•Depression/Affect: screen, Beck Depression Scale •Cognition - screen, MMSE/MoCA •Visual acuity

Miller Fisher Syndrome

•Descending paralysis, proceeding in the reverse order of the more common form of GBS

•Destination Devices VAD

•Destination (Long-term) LVAD Therapy •HeartMate II (Thoratec) •HVAD Pump (HeartWare)

Cauda Equina Injury from:

•Disc herniation, trauma, tumor

PD Treatment Considerations**

•Distractions •Cues •Internal vs. external •Visual vs. auditory vs. tactile vs. structural •Variability •Context •Cues •Timing of sessions? •Fatigue •Co-activation •Osteoporosis

Genitourinary System acute

•Diuresis (due to fluid re-mobilization) •Difficulty voiding (due to positioning) •Urinary Tract Infection (UTI) •Calculus formation (10-15%), hypercalciuria (esp SCI, Fxs)

Medicare coverage of K0005 is determined on an individual basis

•Documentation might/must include info on the pt's diagnosis, abilities and limitations as they relate to the equipment (degree of independence/dependence, frequency, and nature of the activities the pt performs, etc), the duration of the condition, the expected prognosis, and past experience using similar equipment.

MS **Clinical Considerations/Features

•Doesn't physiologically progress the disease, but short-term, increases the interference of existing symptoms with function (maybe from subclinical levels to significant impairment) Humidity - similar effect

An Analogy PD•Dopamine is like a

•Dopamine is like a radio/communications system for the brain to the body •As it goes out, the signal gets quieter or cuts in/out •This makes starting and stopping activities difficult •If it goes out slowly, you may not realize that your communication is impaired.

CVA •Consider if these symptoms exist if it is wise to exercise:

•Lightheadedness or dizziness •Chest heaviness, pain or tightness; angina •Palpitations or irregular heart beat •Sudden shortness of breath not due to increased activity •Discomfort or stiffness in muscles persisting for several days after exercise

•Brain Tumors

•Limited survival •Rehab similar to CVA or TBI •Medical/Surgical treatments -Increase survival -Increase life expectancy •May be progressive in nature •Obstacles for therapeutic intervention -Aggressive tumor growth -Medical management

During an acute flare... MS

•Local inflammation at acute lesion, causing nerve compression and conduction impairments •As inflammation wanes, this mass effect is diminished and symptoms improve •Left with fewer symptoms but long-term damage

PPS pt's

•Long term working relationship is important •Expect resistance - counter-intuitive treatment •Respect & understanding will give high compliance (gradually) •Highly motivated Don't fatigue them, but help them use what they have

Swallowing *** in PD BIG DEAL

•Dysphagia:*** •95% of pt's!! This can lead to aspiration, pneumonia and death! Also trouble with adequate nutrition •Early symptom of disease •Sialorrhea: excessive drooling. Increased saliva production and decreased spontaneous swallowing •Pts with PD have problems in all four phases of swallowing -Chewing and tongue control -Bolus formation -Delayed swallow -Getting food down esophagus •IF you hear coughing/choking with drinking or swallowing, REFER!!!

Dynamic Visual Acuity Testing

•ETDRS LogMAR or Snellen Visual Acuity Chart •Wear glasses •Read lowest line with head stationary --> Normal is <3-line deterioration •Tilt head forward 30 degrees and move head at 2 hz head shake and ask patient to read lowest line again 2 Hz is 120 bpm (set metronome to 120 right/left or 240 if each count is left, right, left, right

MS Positive Indicators

•Early onset •Complete recovery •Non brainstem lesions •Early treatment •Sensory symptoms

Early Medical Management TBI

•Early resuscitation •Stabilize vitals, neuro exam, x-ray films •CT and MRI of head, spine, thorax, and abdomen •LARGE INTRACRANIAL HEMATOMAS ARE EVACUATED Begins at scene of accident •Oxygen saturation >90% •Neck stabilized with collar (in case of instability)

Disease Modifying Drugs: MS: •National Guidelines

•Early, ongoing, and aggressive treatment with these drugs - as soon as diagnosed! •Reduce number of relapses, delay progression of disability, and limit new disease activity •AAN Guidelines for starting, switching, and stopping these drug therapies

Dx GBS •Confirmation:

•Electrodiagnostic studies •Cerebrospinal fluid However, the key for diagnosis is history and physical exam, in differential diagnosis Not one solid test to say conclusively GB

•Supine<>sit CVA

•Emphasize rising from the impaired side because more work is needed here and getting to this position is easier

Gait training: CVA encourage __ steps...

•Encourage even steps, facilitated by rhythmic auditory cues or foot markers

Tx PPS

•Energy conservation and pacing training •Assess assistive devices and consider upgrade - FUTURE need consideration is important, too

Treatment Plan MG

•Energy conservation during periods of symptom exacerbation. •Assess gait/mobility and ensure patient is safe. --> Determine if AD is necessary --> Fall prevention if needed •Establish an exercise program specific to the patient and their functional needs. --> Moderate intensity --> Exercise program should not exacerbate symptoms --> Postural exercises can assist with breathing, speaking, swallowing --> Breathing exercises

Fatigue - Rehab: How do we treat FATIGUE? MS: Interventions

•Energy conservation/pacing strategies •Aerobic exercise program •Cooling •Equipment and environmental modification

•Consequences rigidity PD

•Energy expenditure •Functional movement - rotation •Prolonged leads to contracture- sarcomeres shorten bc dn move

MS: Structured, problem-focused, interdisciplinary interventions to:

•Enhance/maintain function, comfort, safety, and independence over the course of the disease •Educate for self-management and behavior change •Identify appropriate assistive devices and environmental modifications •Prevent injuries and unnecessary complications Empower individual and family"

What happens? MS

•Ephatic transmission: leakage of electrical activity •Ectopic Foci: stim by something else halfway down and causing AP when it shouldn't happen •Slow, incomplete, absent transmission Saltatory- ECM has some potential, adjacent N can collect some elect pot and start and AP - all can lead to distorted or interrupted signlas Like telephone- some of message thru, some changed

pain MS •Interventions

•Equipment mod •Regular relaxation/ stretching •Exercise •Hydrotherapy in lukewarm water (80-84֯ F) --> Postural retraining •Correct movement patterns •Pain management techniques •Activity/environmental mod --> Fatigue

Brain tumor etiology: •Etiology is ______ •Familial incidence can often be explained by _______ •Associated with _______ •Associated with _______ •Ionizing radiation treatment can cause _______

•Etiology is not always clear •Familial incidence can often be explained by environmental exposure •Associated with chemical/material exposure •Petrochemicals, organic solvents, rubber, teflon •Associated with electromagnetic field exposure •Ionizing radiation treatment can cause secondary tumors

In-clinic POC Recommendations MS: •At diagnosis:

•Eval and a few, infrequent follow-up visits (1x/wk or 1x/mo for 3-5 visits) •Primarily for education, exercise monitoring, progression, and exercise program development

•Hydrocephalus CVA

•Excessive accumulation of cerebral spinal fluid (CSF) •Rare but occurs with subarachnoid (SAH) or Intracerebral hemorrhage (ICH). •Increasing blood volume results in obstruction of CSF circulation

•Anterior Canal

•Excitation: ipsi superior rectus, contra inferior oblique

Treatment MS

•Exercise is BEST non-pharmacological intervention! •Physiological Benefits •Overall fitness •Overall strength •Sleep •CV function •Psychological Benefits •QOL •Wellbeing •Mood/cognition •Functional Benefits •Functional mobility/ADLs •Balance •Fatigue - regular low impact ex •Education!! Function, function, function!

Medical Assessments MS

•Expanded Disability Status Scale (EDSS) - Oldest and probably most widely used •Ordinal 0 (normal neuro fxn) - 10 (death due to MS) in ½ point increments

•Occlusion of proximal MCA produces:

•Extensive neurological damage •Significant cerebral edema •Increased intracranial pressure -Loss of consciousness -Possibly death

MG Class II:

•Eye mm weakness, mild weakness of other mms •IIa: predominantly limb or axial mm •IIb: predominantly bulbar/respiratory

MG Class IV:

•Eye mm weakness, severe weakness of other mm •IVa: predominantly limb or axial mm •IVb: predominantly bulbar/respiratory

Common CNS infections

•FUNGAL INFECTIONS •Cryptococcal meningitis •Brain abscess •Spinal epidural infection •PROTOZOAL INFECTIONS •Toxoplasmosis •Malaria •Primary amoebic meningoencephalitis •BACTERIAL INFECTIONS •Tuberculosis •Leprosy •Neurosyphilis •Bacterial meningitis •Late stage Lyme disease •Brain abscess •Neuroborreliosis

Fall training PD

•Falls will happen within this population, so train them to deal!!! •Discuss preparations - have a way to contact help from the floor •Discuss what to do when you fall -Body check -Environment check -What is safe to use to assist •Train how to fall •Train how to get back up •FEAR of falling is major predictor of RISK of falling

Determining prognosis: Positive predictors TBI

•Family support

LMN Clinical Impairments ALS

•Fasciculations are common --> Possibly due to hyper excitability of motor axons •Hyporeflexia •Flaccidity •Muscle cramping •Denervation atrophy (muscle wasting) •Pain •Sensory pathways are typically spared.

Position or Movement Stimulation TBI

•Faster movements patterns tend to facilitate arousal •Monitor patient's BP •Use meaningful and familiar position changes •Avoid spinning (vestibular wise), which may trigger seizures •Watch for early physical protective reactions or delayed balance reactions during these activities

Side Effects of Chemo/Radiation

•Fatigue •Anemia •Hair loss •Nausea •Skin burns/irritation •Difficulty eating •Dry/sore mouth

Other Signs and Symptoms - AIDP

•Fatigue •Muscle tenderness

Physical Examination MG

•Looking upward and sideward for 30 seconds: ptosis and diplopia. --> Sustained up gaze for 1-2 minutes can lead to increased ptosis, which improves after rest. •Difficulty in chewing or swallowing •Keep the arms stretched forward for 60 - 120 seconds •Walking up steps or walking 30 steps on both the toes and/or heels •Limb weakness tends to be proximal and symmetric and should not conform to the distribution of any single nerve, root, or level of the central nervous system. Why?

•Paralytic polio

•Loss of reflexes, severe mm aches, spasms and worsening over time. Majority have strength return. Sensation, sexual function, B&B intact. (bc MOTOR neuron/motor system dz/problem

•Cervical SCI CV imp's

•Loss of sympathetics,

Determining prognosis: Negative predictors

•Low scores (GCS-motor score) •Pupillary reactivity • •Race •Lower educational level •Alcohol or drugs in the system at the time of the injury (and Hx) •Petechial hemorrhages •Subarachnoid bleed •Obliteration of 3rd ventricle or basal cisterns •Midline shift •Subdural hematoma (on CT)

General Recommendation PPS

•Low to Moderate intensity •Non-fatiguing exercise - can improve strength and reduce fatigue (NINDS) •and other non-weight bearing activities •Weight-bearing activities (walking) may be appropriate for some

Chronic SCI: cervical injuries ***Fitness:

•Lower peak heart rate •Post-exercise hypotension •Other abnormal cardiovascular responses to exercise

MS•Criteria: Revised McDonald Criteria (2017)

•MRI may be used to look for a 2nd area of damage in someone with only one attack AND •MRI may be used to confirm that damage occurred at 2 different points in time •Presence of oligoclonal bands in CSF analysis can replace need for dissemination of time •Rule out other diagnoses: --> Medical history and clinical neurologic exam (CN, sensation, reflexes, coordination, balance, gait) --> Blood tests to rule out others: lupus erythematosus, Sjogren's, vitamin/mineral deficiencies, infections, rare hereditary diseases

Macrophage involvement GBS: •Macrophages _____ • •In milder forms of GBS, ______ • •Axonal loss is related to ______

•Macrophages attack and strip the myelin sheaths and in some cases the axons. • •In milder forms of GBS, the axons are left intact and the nerves are remyelinated. • •Axonal loss is related to long-lasting or permanent muscle weakness seen in some patient's.

PD: •Make sure you are attending to ____ •Be ____ in your exam/treatment •Use____

•Make sure you are attending to non-motor deficits •Be efficient in your exam/treatment •Use neuroplasticity principles!

MS Negative Indicators

•Male •Late onset (>35 y/o) •Multiple regions in attacks •Incomplete recovery •Brainstem lesions •Late treatment •Tobacco use •Obesity •Hyperlipidemia •Psychiatric comorbidities (including anxiety and depression)

gender GBS

•Male to Female = 2:1 (starting to be •more equal)

Dysarthria ALS

•Managed by SLP •Initially intelligibility strategies --> Exaggerate articulation or decrease the rate of speech •As severity progresses, decrease dependence on speech as primary method of communication --> Low-tech device (pad and pencil), alphabet board --> High-tech devices (computer with voice synthesizer)

•Functional Gait Assessment:

•Max Score 30 •Community Dwelling older adults: •≤22/30 effective in predicting falls •Parkinson's Disease: •≤18/30 identifies a fall risk

MiniBESTest:

•Max score 28 •Chronic stroke: ≤17.5 identified those with a history of falling •Parkinson's: 16/32 adequate ability to predict 6-month prospective fallers

Motor Function CVA

•Measurement using Brunnstrom's Stages of Hemiplegic Recovery •Individual recovery is highly variable •The recovery process can plateau at any stage

Invasive O2 Delivery

•Mechanical Ventilation - Endotracheal Tube: --> Patients are intubated. --> For planned extubations, allow 2-3 hours before mobilization. -Tracheostomy: --> Long-term ventilation. --> Avoid mobilization on day of tracheostomy. --> May possibly come off ventilator during mobilization with "trach collar".

Symptomatic Management ALS

•Medical management often considered palliative •Palliative: achievement of the best possible quality of life for patients and their families. •WHO defined palliative care: "the active total care of patients whose disease is not responsive to curative treatment".

Classification of a High Strength Lightweight Manual Wheelchair***

•Medicare Code: K0004 •Characteristics: •Weight <34 lbs •Seat width 16", 18", 20"*** •Seat depth 16" and 18"*** •Weight capacity ≤250 lbs •Life-Time Warranty on the side frames and cross braces

Classification of an Ultra-Lightweight Manual Wheelchair

•Medicare Code: K0005 •Characteristics: •Weight < 30 lbs •Seat width 15-19"*** •Seat depth 15-19"*** •Weight capacity ≤250 lbs •Adjustable rear axle •Lifetime warranty on the side frames and cross braces

Primary Brain Tumors

•Meningiomas (dura mater or arachnoid membrane) •Pituitary Adenomas (hyper/hyposecretion of hormones) •Schwannomas (cranial or spinal nerves) •Primary CNS lymphoma

Variant forms GBS: of the rare syndromes this is most common

•Miller-Fisher Syndrome (MFS)-

Summary of direct impairments

•NM: sensory, motor function, balance, paresis •Cognitive: consciousness/alertness, memory, orientation, attention, insight and safety, problem solving, perseveration, executive function •Visual •Perceptual •Neurobehavioral: disinhibition, impulsive, aggressiveness, apathy, lack of concern, egocentricity •Communication: aphasia, dysarthria, auditory deficits, reading comprehension, written expression, pragmatics (use of language) •Dysphagia

•Low Flow O2 Delivery:

•Nasal Cannula: Max 6L •Prongs curve downward •Simple O2 Mask, aka "Oxymask" •Partial Rebreather O2 Mask

•Long-term sequalae TBI

•Neurodegenerative and psychiatric disease •Alzheimer's, Parkinson's, frontotemporal dementia, CTE •Depressive and anxiety disorders

Exacerbations = Relapses = Attacks = Flares MS

•Neurologic symptoms lasting >24 hours (new or recurrent) -Unrelated to other cause (infection, illness) -Separated from previous attack by at least 30 days

Secondary Parkinsonism

•Toxic Parkinsonism •Exposures - most common manganese, synthetic heroin •Drug-Induced Parkinsonism (DIP) •Metabolic Causes •rare cases: disorders of calcium metabolism, hypothyroidism, hyperparathyroidism, hypoparathyroidism, and Wilson's dz Drug induced parkinsonism (DIP): Withdrawal of these agents usually reverses the symptoms within a few weeks, although in some cases the effects can persist and may be related to subclinical PD. a lot of drugs can produce extrapyramidal dysfunction that mimics the sign of PD. These drugs are thought to interfere with dopaminergic mechanisms either presynaptically or postsynaptically.

UE support devices•Non ambulatory patients:

•Trays, troughs on w/c

Early s's PD

•Tremor- not the ealiest •Small Handwriting • •Trouble Sleeping •Trouble Moving or Walking •Constipation •Soft/Low Voice • •Dizziness/Fainting •Stopping or Hunching Over

Understanding Lab Values

•Trends •Risk vs Benefit of Therapeutic Intervention •Acute vs Chronic Considerations •Gender, Race, and Cultural Considerations •Age Considerations

Cardiac •Troponin: > ____ ng/mL indicative of acute MI •____ trending - proceed •____ trending - hold

•Troponin: > 0.06 ng/mL indicative of acute MI •Down trending - proceed •Up trending - hold

Common Gait Deviations with CVA***: Swing Phase: Trunk/pelvis

•Trunk rotation to step, lateral lean

Mobility base: Prescriptive wheelchair

•Tubular frame •Armrests (UE support) •Foot supports •Wheels

Integumentary/Sensory GBS: Key is skin protection in early stages

•Turning/positioning schedule •Special mattress/bed •Pressure relief schedule •Good cushion and w/c positioning •Be aware of splints, wrinkles

•Motor Function MS

•UMN signs •Cerebellar Signs •Gait - speed, endurance, stability, safety •Review AD/Wheelchair •Aerobic Capacity/ Endurance -

Prior Level of Function acute

•What is their home environment like? •What equipment are they accustomed to using? •What equipment do they have available? •Did they require physical assistance prior to hospitalization? How much and with which activities? •What was their mobility like? •Which activities did they participate in before? What was their activity level? •Do they still work? What do they need to get back to doing? Dec bedrest and LOS Sometimes only see them once or twice- so recommending dc location and services- good for prior environ, or need to go where more services

Functional Abilities**

•Wheelchair mobility •Wheel position (manual) •Axel position forward/backward •Axel position higher/lower •Hand control position (power) Alternate drive options What does: Axel forward/backward do: (loss of legs, shoulder position) Axel higher/lower do: height of patient, leg propeller. (make students explain) On power chair can set drive box anywhere- retainer, baseball cap - if mvmt create a way fo rhtem to drive

Wheelchair ALS

•Wheelchairs allow pt to maintain their previous activity level •Manual w/c can be nice but often they soon need a power system and insurance won't purchase a second •Power w/c: Prepared for the future. A scooter may be fine now, but in the near future it will not be appropriate.

Tempo: Main framework

•When patient's dizzy for years, find out what is bringing them in NOW.

Discharge/Follow-up PD

•When plateau •When they and/or family can progress themselves •When goals are met

MG Assisted Ventilation

•With bulbar involvement, paralysis of respiratory muscles necessitates assisted ventilation. •Crisis can be triggered by infection, fever, adverse reaction to medication, or emotional stress (previous list). •The heart muscle is regulated by autonomic/ somatic (which?) nervous system, it is generally affected/ unaffected by Myasthenia Gravis.

•Aerobic: PPS

•Work up to 20-30 min/session (performed in intervals initially for sedentary clients)

•Requirements for group 3 power wheelchairs

•Written order (mobility limitation due to neurologic condition) •Face-to-face mobility examination (for wheelchair, not during check-up) •Home Assessment •Evaluation by specialized PT/OT AND ATP •Requires alternative drive control interface (head control, sip-n-puff, switch) AND power tilt/recline OR ventilator

Active restraint- spastic antagonist mm's

•You can safely strengthen agonist and antagonist muscles without detrimental increase in spasticity

Cog imp TBI: Altered level of consciousness occurs with

•acceleration-deceleration type injuries (DAI) and some focal injuries

Brunstromm•Stage Six- mvmt

•all types of prehension (grasps) can be controlled; individual finger movements present

Anti-arrhythmia medication

•amiodarone

AIDP: Caused by

•an autoimmune responses directed against Schwann cell membranes •Primarily demyelination •Distribution of inflammation corresponds to clinical deficit So if you have demyelination of the schwann cells in the legs, you get leg weakness, in the nerves that control the respiratory muscles, you get respiratory dysfunction

contractures sci

•begin with alterations in muscle tissue but rapidly progress to involve capsular and pericapsular changes. Emphasize ROM/stretching program

Exercise prescription: PPS: D/C if

•causes additional weakness, excessive fatigue or prolonged recovery time *****No muscle should be exercised to ache, fatigue or weakness

MS is

•chronic and unpredictable, with no know cause and no cure •Lots of variability within and between patients •Early diagnosis, early medication, and EARLY exercise

***Clinical Presentation*** PD

•chronic, progressive disease of the nervous system with motor and non-motor symptoms. •2 subtypes: •Tremor predominant = ~70% •Postural Instability/Gait Dysfunction = ~30% • • •Usually asymmetrically presentation

Neurobehavioral Impairments: Closely linked to

•cognition

As pressure rises- the artery is stretched -

•contraction of smooth muscle in the vessel wall - patency of vessel is decreased = ↓ CBF

Field defects

•contribute to the patient's overall lack of awareness of the hemiplegic side.

CVA Spastic posturing can lead to

•development of painful spasms, degenerative changes, fixed contractures

•Foley Catheter:

•drains urine -> collection bag; for patients unable to mobilize to restroom; incontinent, sedated, comatose, etc. •Know where Foley line is at ALL times. Attach to PT belt loop/pocket during transfers/bed mobility.

Atypical Parkinsonism/Parkinson-Plus Sydromes: •early in these diseases courses, these diseases may present with ____ and _____ indistinguishable from PD •a diagnostic feature:

•early in these diseases courses, these diseases may present with rigidity and bradykinesia indistinguishable from PD •a diagnostic feature: typically do not show measurable improvement from the administration of anti-Parkinson medications such a L-dopa (levadopa) therapy (termed the apomorphine test)

Scapula in CVA

•emphasize upward rotation and protraction

Research PD Animal models:

•exercise is neuroprotective AND neuroregenerative •Can't confirm neuroregenerative in humans

CPG (Central Pattern Generator) -

•exists in the ventral spinal cord

Validation of NDT (Neuro IFRAH**)

•failed to support it over conventional exercises.

Seat Support: Firm seat:

•good LE alignment, good pressure distribution and improved comfort

Neurorecovery and functional performance are enhanced after cortical infarction when post injury training incorporates motor tasks of

•greater complexity and higher-intensity demands than training conditions that do not

Parkinsonism

•group of disorders that produce abnormalities in dopamine systems of basal ganglia (BG) function •Idiopathic Parkinsonism •Secondary/Symptomatic Parkinsonism •Parkinson's-plus syndrome/atypical parkinsonism

Atypical Parkinsonism/Parkinson-Plus Sydromes

•groups of neurodegenerative diseases affecting substantia nigra, produce parkinsonian symptoms (and other neuro signs) •normal pressure hydrocephalus, Creutzfeldt-Jakob disease, Juvenile Huntington's disease, diffuse Lewy body disease, etc.

Wheelchair CVA

•hemi-height- (lower seat to floor height at 17.5 inch vs regular at 19.5 inch) •Power wheelchairs are sometimes warranted

ALS PT Intervention: Restorative:

•in late stages the restorative may be toward remediation of impairments that result from other system pathology (sores, edema, pneumonia, atelectasis, adhesive capsulitis)

•Two main types of apraxia: Ideational apraxia:

•inability of the patient to produce mvmt either on command or automatically

Phase 5. Pre-Swing: angles increasing or decreasing

•inc ankle PF, knee ✔; dec hip extension •Hip 10o hyperextension (apparent) •Ankle 15o PF

CVA: Slow rocking mvmts also

•increase inhibitory effects through adding influences of slow vestibular stimulation.

CVA Balance Retraining Goals:

•increase the consistency, range, and speed of self-initiated movements while encouraging symmetry and maximum use of the more affected side Stress: symmetrical weight bearing, as well as activities that promote shifting toward the more affected side.

Incidence of brain tumors is

•is on the rise •Cause for the increase is unknown •May be partly due to improved imaging/diagnosis

Strength: PPS

•isometric OR concentric/eccentric •Non-fatiguing

Increased passive range of motion of knee extension of at

•least 10 degrees

Gait training: CVA Progress ASAP to

•least restrictive device possible

As pressure falls-

•less contraction smooth mm - increase patency = CBF ↑

Non-Motor Symptoms: PD

•masked face •Pain and paraesthesias - postural stress syndrome •Visual symptoms: conjugate gaze, saccadic eye mvmts, smooth pursuit may be impaired •Cognitive: 20-40% patients bradyphrenia, visuospatial •Depression/ dysphoria •Autonomic issues: seborrhea, sialorrhea, thermal dysregulation, constipation, sexual and bladder dysfxn •Cardiopulm: orthostasis, ↓ in heart rate response, Arrhythmias (linked to meds, as well), insufflation/restriction, low BP •Sleep: insomnia, daytime somnolence, REM sleep behavior d/o (50-60%)

•Beta Blockers

•metoprolol, propranolol

PT Intervention: Preventative: ALS

•minimizing potential impairments (ROM, aerobic capacity, strength, preventing pneumonia/atelectasis, and functional imitations).

•SEATING PRINCIPLES pelvis

•move down, then up •Pelvic position significantly impacts spine/trunk posture

Trunk/assessment/positioning Goal:

•neural alignment while maximizing function •May not always be able to achieve both

Expected outcomes of serial casting include: Improved tolerance to

•passive manual stretching of affected extremity following each successive cast application

•Two main types of apraxia: Ideomotor apraxia:

•patient is unable to produce a movement on command but is able to move automatically (even if not correctly: brush teeth with comb)

Improving Motor Function: terminal stretch performed

•performed daily in all motions •Protective devices are useful •Resting hand splints

MS: Symptoms may be

•permanent or may come and go, seemingly at random

Pharmacology PD: COMT Inhibitors:

•prevent wearing off by inhibiting metabolism of dopamine (entacapone and tolcapone); used as adjunct to levodopa;

Vertebrobasilar Artery Syndrome

•produce a wide variety of symptoms with both ipsilateral and contralateral signs (some tracts have crossed, others have not yet).

•Sedatives

•propofol, midazolam, morphine, fentanyl, haloperidol Sedatives: how awake and alert are they- If vent AND sedated- cant work with them when unconsc- not skilled therapy

Wheelchairs CVA: Severely impacted patients start with

•reclining w/c

Most efficient:

•semi-circular Educate the patient to use long, smooth strokes that limit high impacts on the pushrim. • Educate the patient to allow that hand to drift down naturally, keeping it below the pushrim when not in actual contact with that part of the wheelchair.

•Spinal shock may last:

•several days to several weeks • impaired autonomic regulation •Hypotension, loss of sweating and piloerection

•Rectal Tube:

•similar usage as Foley. •Know where the Rectal tube is at ALL times. Avoid scooting as able, as it may easily dislodge.

CVA- Paroxysmal spasms of pain from

•simply stroking the skin, pinprick, contact with heat or cold or pressure (hyperalgesia)

Left paretic lesion: (by Alexander's law- gaze towards fast phase intensifies it)

•slow drift toward the side (left) •corrective motion rightward observed as right-beating nystamus (fast phase) •if person gazes to the left it suppresses nystagmus •if person gazes to the right (fast phase) it intensifies the nystagmus

Sensory impairments CVA: Cortical lesions:

•specific localized areas

Posterior Cerebral Artery Syndrome***Clinical Manifestations: •Central territory

•spontaneous pain and dysesthesias, sensory impairments •Involuntary mvmts: choreoathetosis, intention tremor, hemiballismus •Contralateral hemiplegia •Weber's syndrome •Paresis of vertical eye mvmts, miosis, ptosis, sluggish pupillary light response—CN III

Timed Up and Go

•stand-up, walk 3 m (10 ft), turn around, and return to chair. •Elderly: <10 sec=independent; > 30 sec dependent

Disease Modifying medications -MS

•start early and ongoing, very little to treat PPMS •Injectable medications •Oral medications •Infused medications

MG •Surgery:

•surgical removal of thymus (70 - 80% of MG patients have hyperplastic changes in their thymus).

Heterotopic Ossification:

•swelling, jt and mm pain, decreased ROM, erythema, warmth

•Hypoxic-ischemic injury:

•systemic hypotension, anoxia, damage to specific vascular territories

Serial casting exclusions:

•Uncontrolled intracranial pressure •Marked edema at the extremity to be casted •or recent fracture at the extremity to be casted •Decreased bone density at the extremity to be casted •Bony restriction of joint, hard end feel at the extremity to be casted •Painful arthritis at the extremity to be casted •Need for limb access for monitoring vital signs and medication administration at the extremity to be casted • including recent deep vein thrombosis •Longstanding or fixed contracture at the extremity to be casted

acute: Medical History

•Underlying co-morbidities •Examples: Hypertension (HTN), Diabetes Mellitus (DM), Congestive Heart Failure (CHF) •Multiple current diagnoses •Examples: Fractures, cardiopulmonary conditions, seizures, iNPH, vestibular impairment Don't give drink of water if walk in and say thirsty- if R back s into legs and L if bad backs to lungs and legs When someone has a stroke, high risk for seizures In acute- often actually do see vestibular in hospital

MS Etiology

•Unknown, but... Thought to be auto-immune No specific antigens have been identified -A lot of people talk about as autoimmune, but theres no specific antigen to ID, so immune mediated officially

Infections •Prevention

•Vaccination for haemophilus influenza type B in young children/infants (and college freshmen)

In-clinic POC Recommendations MS: •With progression:

•Variable timing: 1-2x/wk to less frequent once equipment needs/activity mod addressed •Assistive/adaptive device assessment and recommendation; encouragement/persuasion to use "tools" appropriately •Consider how instruction, education, and recommendations are communicated

Onset of recovery GBS: • •----% become ambulatory within -- months •Most common long-term deficits: •Rec within •---% have remaining symptoms

•Varied, gradual recovery of muscle strength 2-4 weeks after progression has stopped or plateaued •80% become ambulatory within 6 months •Most common long-term deficits: weakness of anterior tib, foot and hand intrinsics, quads, gluts, fatigue and endurance •Rec within 6- 12mths •15% have remaining symptoms

Etiology SCI: Nontraumatic Damage (disease or pathological influence)

•Vascular dysfunction (AVM, thrombosis, embolus, hemorrhage), spinal stenosis, spinal neoplasms, syringomyelia (a pocket inside SC with an infection or fluid filled pocket- bc spinal canal fixed dia, if fluid filled inside crushes inside contents- could be tethered cord- not solid, just a space occupying fluid- serosanguinous or CSF< itself not dangerous, but bc crushed SC kinda), infections, neurological diseases (MS, ALS)

Spastic Hypertonia

•Velocity-dependent increase in resistance to passive stretch •UMN syndrome: spasticity, muscle spasms, abnormally high muscle tone, hyperactive stretch reflexes, clonus •These terms may be used interchangeably in the literature

Posterior Cerebral Artery Syndrome***Clinical Manifestations: •Peripheral Territory:

•Visual agnosia (trace the letter and then know what it is), prosopagnosia •Dyslexia without agraphia, color anomia

Intervention Ideas - How to GET the results? PD

•Visual cues - laser lines, tape/tile, step over inverted cane •Large amplitude movements - Big Training (LSVT Big, PWR) •Speed of Gait is important predictor of function and safety •Think neuroplasticity •Intensity/difficulty!! - Important/specific - Repetition - Frequency - Complexity •Fun and function - if it doesn't matter and isn't fun, it won't be done!

Pathophysiology—Interrupted blood flow CVA: Ischemia triggers

(•-potentially reversible events) •excess neurotransmitters (glutamate and aspartate) --> progressive disturbance of E metabolism and anoxic depolarization --> brain cells can't produce energy (ATP) --> excess influx of calcium and pump failure of the neuronal membrane •Excess calcium: reacts with intracellular phospholipids to form free radicals •Calcium influx: stimulates release of NO and cytokines •Both mechanisms further damage brain cells

____ Americans living with PD

1 million Americans living with PD (more than MS, ALS, and MD combined)

3 mechanisms of primary blast injury:

1- direct transcranial blast wave propogation 2-transfer of kinetic energy from the blast wave thru the vasculature, triggering pressure oscillations in the blood vessels leading to the brain 3- elevations in CSF or venous pressure caused by compression of the thorax and abdomen and by propagation of a shock wave through the blood vessels or CSF

Intervention Goals GBS

1.Facilitate resolution of respiratory problems and dysphagia 2.Minimize pain 3.Prevent contractures, decubitus ulcers, injury to weakened or denervated muscles 4.Introduce a graduated program of active exercise while monitoring overuse and fatigue 5.Resume psychosocial roles and improve QOL

as high as ___% of people with tetraplegia experience autonomic dysreflexia.

85

Anterolateral spinothalamic type of sensation

(tickle, itch, sexual sensations); poor spatial orientation

LOC* Loss of Consciousness severe TBI

>24 hours

rancho 6

Berg, goal specific fwx that pt wants to get back to

CARF:

Commission on Accreditation of Rehabilitation Facilities

Difficult initiating tasks,

L

gender PD

Men 1.5x as likely as women

Assaults and violence TBI

9%

Patient cannot (LIS)

Patient cannot move or speak but remains alert and oriented

____ 24 hrs, _____ 1-3 days post injury, increasing ____ 1-4 weeks and _______ 1-6 mos.

Areflexia, gradual return of reflexes, hyperreflexia, final hyperreflexia

Abstract reasoning

R

LMN: with cauda equina

Areflexic bowel and bladder, saddle anesthesia

Arms and legs (brunstrom)

Arms and legs can be at different levels

Anterolateral spinothalamic origin

Skin: mechano, thermo, nociceptors

Eye exam and Gaze stabilization:

VOR, HIT, after head shake

3rd deg heart bl

dc ther immed , notify med staff asap

Strong spasticity:

deterrent to independent function Stretch hip lfexors, abdominals, heel cords

Surgical management PD:

duopa and dbs

C3-4

levator, scalenes

below the level of injury: AD

pale, cool skin cold, clammy and piloerection

Incidence: GBS

• 1-4/100,000 individuals = Rare

Level of cord injury and the degree of respiratory dysfunction 1st pt

•High cervical (C1 or C2)

GBS prediscposing factors

•No consistent predisposing factors are known

Prognosis PD •usually a •pt's who have a ____ or who are _____ typically demonstrate a more benign progression and a relatively good prognosis pt's who present with ____ and ______ (PIGD) tend to have a more pronounced deterioration with a more rapid disease progression •Mortality is usually due to _____ or ______

•usually a long subclinical period (without apparent clinical manifestations), about 5 years •pt's who have a young age at onset or who are tremor predominant typically demonstrate a more benign progression and a relatively good prognosis •pt's who present with postural instability and gait disturbance (PIGD) tend to have a more pronounced deterioration with a more rapid disease progression •Mortality is usually due to cardiovascular disease or pneumonia

MCA Clinical Manifestations: Dominant hemisphere*(

•usually left): "Left CVA" Wernicke's/sensory/receptive aphasia) - •auditory association cortex of the left lateral temporal lobe •Means that most people that are right handed are left brain dominant and most of the population is right handed.

acute: Prepare yourself to:

•weigh the risks of bedrest and mobilization •identify precautions and contraindication of mobilization •describe how to manage lines •select safety measures to progress mobilization

motor units in CVA

•↓ functioning motor units •↓ discharge firing rate •Abnormal recruitment of motor units

•Pulmonary Function in CVA

•↓ lung volume, ↓ pulmonary perfusion and vital capacity, altered chest wall excursion •Aspiration: penetration of food, liquid, saliva, or gastric reflux into the airway (1/3 of CVA's with dysphagia experience aspiration) •Aspiration can lead to acute respiratory distress (ARDS) in hours or death if untreated. •Eval with MBS or FEES

GBS: •Early therapy correlated with •DO NOT

↑ recovery potential OVER FATIGUE!

Basal Ganglia Review: Three main nuclei:

◦Caudate nucleus - input ◦Putamen -input ◦Globus pallidus- output

Motor control impairments

◦Monoparesis ◦Hemiparesis ◦Tetraparesis ◦Impairments: Coordination Timing Sequencing of movement

2 other subcortical nuclei considered part of basal ganglia

◦Subthalamic nucleus ◦Substantia nigra

Benign Paroxysmal Positional Vertigo (BPPV)

- Often diagnosed in beauty pallor or dentist office •Majority of cases idiopathic cause •Symptoms secondary to displaced otoconia Success Rates: 80% with 1-3 treatments

2.Saccade

(15 degrees off center to right and left) •Head fixed, rapid repositioning of eyes to refoveate •Look for: velocity, accuracy, disconjugate motion

Limited knee flexion in LR

(<20 deg) Intentional to decrease demands on weak quads 2° PF or quad tone, spasticity, or contracture proprioceptive impairment at knee. Analysis: examine strength, tone, spasticity of PF and quad; PF and knee extension Rom; knee proprioception

Anticonvulsants:

(Dilantin), Tegretol, etc. Seizures can be life threatening if not controlled.

•Sensory symptoms GBS

(distal hyperesthesia, paresthesia, numbness, decreased vibratory or position sense - stocking-and-glove pattern)

•Pulmonary complications are a leading cause of death SCI

(early and late stages of recovery)

choreoathetosis

(fast or slow involuntary mvmts)

Stereotactic Radiosurgery (brain surgery)

(high dose radiation to a small, precisely-defined volume of tissue)

•Vasopressors

(improve Systemic Vascular Resistance (SVR) and Blood Pressure) i.e: phenylephrine, norepinephrine, epinephrine, dopamine, vasopressin

Weber's syndrome

(ipsilateral oculomotor palsy and contralateral hemiplegia)—CN III

HIT neg

+ DCN, +Skew Stroke - DCN, no spont nyst, neg skew and + Dix BPPV

Sleep apnea is an independent risk factor,

, doubling the risk of stroke or death (early menopause=<42 years of age)

Poor Balance/Fall Risk - Rehab: MS: •Assessment

- >50% fallers •Vestibular, visual, sensation •Berg Balance Test •TUG •DGI/FGA •Tinetti •DHI •Strength, endurance, Observational gait analysis

Adjust the rear axle as far forward as possible without compromising the stability of the user.

- Decreases rolling resistance - Increases contact angle - Less muscle effort - Lower push frequency - Smoother joint excursions

High Flow O2 Delivery:

- High Flow Nasal Cannula: MAX 15L - Non Rebreather O2 Mask

Propulsion Technique • Semi-circular pattern is associated with

- Lower stroke frequency - Greater time spent in the push phase - Less angular joint velocity and acceleration • Semi-circular pattern decreases abrupt changes in direction and extra hand movements

Distinct Triad of Symptoms:

-Nuchal rigidity -Sudden high fever -Altered mental status

So, decreased dopamine, we expect...

-Reduced attention -Reduced motivation and arousal -Mood dysfunction -Reduced cardiac output -Increased orthostasis -Urinary retention -GI upset (expected based on what dopamine does)

The three major tracts of the spinothalamic system include

. anterior (ventral spinothalamic tract which carries the sensatios of crudely localized touch and pressure 2. the lateral spinothalamic tract, which carries pain and temp 3. spinoreticular tract, which is involved with diffuse pain sensation.

Optimal Fit WC Prevent problems with:

1)Mobility 2)Posture 3)Function pressure sores, Cosmetics, durability, weight, intended use (considered in optimal w/c.

Medicare Part B (Medical insurance) covers power-operated vehicles (scooters), walkers, and wheelchairs as durable medical equipment (DME).

1- doctor submits written order 2- you have limited mobility and meet ALL of these conditions: health condition causes significant difficulty moving around your home unable to do MRADL even with cane, crutch, or walker you can safely operate w/c or scooter (and get up and off) Your doctor who's treating you for the condition that requires w/c or scooter and your supplier are both enrolled in medicare you can use the equipment in your home (through doorways, etc.)

Diagnosis of ALS requires presence of: Absence of:

1. LMN sign (clinical, electrophysiological, neuropathological exam) 2. UMN sign by clinical examination 3. Progression of the disease within a region or to other regions by clinical exam or via the medical history Absence of: 1. Clinical, electrophysiological, and neuroimaging evidence of other diseases that may explain UMN and LMN signs 2. Oculomotor involvement, sensory signs, sphincter control problems

Diagnostic Testing: determine...

1. Determine which CANAL 1. Quality of nystagmus to identify what canal needs to be treated 2. 3 canals each provoke unique eye movements 3. Determine the form of BPPV

ALS The 4 regions are:

1. bulbar 2. cervical 3. thoracic 4. lumbar

Pressure Sores/Decubitus ulcers: Risk Factors

1.Tetraplegia 2.Spasticity 3.Bladder or bowel incontinence 4.Limited mobility and self-care 5.Nutritional deficiencies- many times depressed and ddont want to eat- have to get high protein and enough calories for skin to be healthy 6.Prolonged immobilization during recovery 7.Smoking 8.Noncompliance with skin care

Prognosis*** SCI

1.The degree of pathological changes imposed by the trauma 2.The precautions taken to prevent further damage during rescue 3.Prevention of additional compromise of neural tissue from hypoxia and hypotension during acute management. ***AIS B, C, D greater chance of good prognosis Even 70% of ASIA A are likely to experience one level of motor recovery below the original neurological level

**Types of MS

1/3 each typically (Mi, mod, sev)

PD OM's

10 meter walk FGA 5xSTS Montreal Cog Assessment Recommeneded for specific constructs: - freezing of gait questionnaire -Parkinson's fatigue scale

__ of deaths due to pulmonary embolism (CVA)

10%

with complete tetraplegia develop pneumonia or atelectasis 1 year after injury

10%

Pressure ulcers SCi

15% (25% within 25 years)

GBS•Approximately ____% of pt's have no identified preceding illness. (That we can identify...)

27

•Normal walking speeds range from

2-3 mph

•Swelling subsides and disappears by

2-3 weeks

DVT SCI

2.5%

GBS: •≥ ____ had symptoms of an infectious disease ____ weeks before the onset of GBS

2/3 2

LR: ____hip flexion

20 deg

AIDP: vent? ANS? sensory? pain?

20-38% require assisted ventilation (weakness of intercostal and diaphragm mm) 50% have ANS symptoms: low cardiac output, cardiac dysrhythmias, marked fluctuation in blood pressure Sensory symptoms (distal hyperesthesias, paresthesias, numbness, decreased vibratory or position sense (stocking-and-glove pattern) Pain---common presenting symptom

Sens exam: ___ dermatomes

28 dermatomes (C2-S4/5)

Areflexia __, gradual return of reflexes ______, increasing hyperreflexia _____ and final hyperreflexia _____

24 hrs 1-3 days post injury 1-4 weeks 1-6 mos.

Inferior vena cava filter

25 mm If US or venogram and det, put IVC filter- thru fem art weave up and put there to catch all clots- anticoag so dissolve clot

Estimation that ___% of all polio survivors may experience PPS, with ___% experiencing post-polio sequelae

25-40 70

Pain and SCI

26-96% of people with SCI report chronic pain

Limited knee flexion in Pre-swing and initial swing:

2° PF tone, spasticity or contracture that limits forward tibial progression in TSt quad tone, spasticity proprioceptive impairment at knee knee pain or effusion calf weakness or hip flexion contracture that limits ability to achieve the trialing limb posture in TSt ISw, weakness of knee flexors also may contribute Analysis: examine tone and spasticity of PF, vastii and rectus femoris; ROM and knee proprioception. Pain and effusion. Examine PF str and hip flexion contracture. Evaluate if these inhibit optimum limb posture

Most of the standard literature suggests

3 ft/sec

Patients who receive tPA within

3 hours are at least 33% more likely to recover from their stroke with little or no disability after 3 months as compared to those who do not receive the treatment.

What is the speed required to safely ambulate across the street?

3 m/sec

Early Warning Signs: Thrombolytic therapy (t-PA) must be given within

3 to 4.5 hours of onset of symptoms

GBS: Almost all reach nadir by

4 weeks. (Some as quick as a day or two).- can progressively decline more and more for 4 weeks,

MS Cognitive Changes -

40-60%

•____% of patients with ALS, inherited it as an autosomal dominant trait (_____) •Rare cases of juvenile onset ALS are _____ •The large majority of adult individuals with ALS have ______

5-10 familial ALS [FALS] inherited in an autosomal recessive pattern no family history of the disease (sporadic ALS)

Limb onset vs Bulbar-onset:

5-year survival is about 37-44% in limb-onset compared to about 9-16% in bulbar-onset

GBS: -___% have ANS symptoms (____).

50 low cardiac output, cardiac dysrhythmias, marked fluctuation in blood pressure

____Americans diagnosed each year PD

60, 000

of people with SCI have spasticity (more common in C-spine injuries)

65%

Specific to Benign Paroxysmal Positional Vertigo (BPPV): }Incidence of BPPV was __X greater >___ }Only ___% had been offered/received treatment

7 60 8

Ependymomas -

70% originate in the 4th ventricle

•____% of individuals develop limb-onset ALS, with initial involvement in the extremities. •which extr? •____% develop bulbar-onset ALS, with initial involvement in the ___

70-80 UEs or LEs 20-30 bulbar muscles.

SCI: Flaccidity, loss of reflexes more than

72 hrs

walking speed predicts post hospital dc locaitions

78% of the time

Incidence of contracture in patients after traumatic brain injury is

84% with 76% occurring at the ankle

Strengthening Guidelines and Parameters: Assessment: MS

: 5 time sit-to-stand, MMT

Initially blood pressure is low: SCi

: bradycardia and dilation of the peripheral vasculalture, lack of or decrease in active mm contraction and prolonged time in bed,

Oscillopsia:

: illusion of stable objects moving in the environment owing to loss of gaze stability

***Normal blood pressure is lower than able-bodied peers:

: range of 90-110 mmHg

*Expiration is passive:

: so airway clearance is often needed the more rostral the injury

Custom hinged:

: solid ankle or hinged. Wider lateral brim and can provide addition control of calcaneal and forefoot inversion and eversion. Solid ankle provides maximum stabilization through it lateral trim lines that project more anteriorly.

•FiO2

< 60%

need intervention to reduce falls risk

<1.0

•Idiopathic Parkinsonism

= Parkinson's Disease: most common form, affecting 78 -85% of pt's

frequ aman and aidp

AIDP: China: 20% Japan: 40% AMAN: Europe and N America :<10% China 60-80% Japan: 40%

Preceding infection AIDP AMAN

AIDP: Cytomeglavirus Campylobacter jejuni Epstein-Barr virus AMAN Campylobacter jejuni

recovery aman and aidp

AIDP: Generally Good AMAN: Two patterns: Rapid or slow

Arterial lines

A-lines measure arterial blood pressure (ABP) & blood gases. The BP monitor must be at the level of the phlebostatic axis (4th rib) for accuracy. It is inserted into radial (most common), femoral, or brachial artery. OK to mobilize with all, including femoral

Categorization of Inflammatory Disorders

A. Brain Abscess B. Meningitis (leptomeningitis) 1. Bacterial meningitis 2. Aseptic meningitis (viral) C. Encephalitis 1. Acute viral 2. Parainfectious encephalomyelitis 3. Acute toxic encephalopathy 4. Progressive viral encephalitis 5. "Slow virus" encephalitis (prion diseases)

add'l measurements

A.Knee flexion angle B.Back height C.Back height (lower scapula)* D.Back height to top of shoulder* E.Back height to occiput* F.Back height to crown of head* G.Arm rest height* H.Width of trunk I.Depth of trunk J.Width of hips* Foot length

A manual wheelchair is covered if:

A.The pt's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker**. B. C.Use of a manual w/c will significantly improve the pt's ability to participate in MRADLs and the pt will use it on a regular basis in the home. D.The patient has not expressed an unwillingness to use the manual wheelchair that is provided in the home. E.The patient has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair provided in the home during a typical day. - limitations of strength, ROM, or coordination, presence of pain, or deformity or absence of one or both UE's are relevant to the assessment of UE function

Mechanical Ventilation What is the ventilator mode? What is the level of FiO2? When are the weaning trials?

AC, SIMV, CPAP, (PEEP, Pressure support) PEEP < 10 cmH2O to begin safe mobilization FiO2 < 0.6 to begin mobilization During weaning process, consider scheduling mobilization when patient is at the higher mode of ventilation

DTRs aman and aidp

ADIP: Absent AMAN: Usually absent Occasionally exaggerated early

T6-10

Abdominals Abdominals, serratus

•_____ support abdominal viscera, maintaining position of diaphragm •They push diaphragm ______ during forced expiration •Without _____, diaphragm assumes a___position, making expiration less ____ •Decreased _____ •Decreases ______ •Decreases ______

Abdominals upward abdominals low passive expiratory reserve volume cough effectiveness ability to expel secretions

Sensory impairments CVA: Crossed anesthesia:

Abnormal sensations also common (numbness, dysesthesia, hyperesthesia)

Limbic system:

Active with addiction and "reward" but also with PTSD and paranoia - so signals "PAY ATTENTION TO THIS" -dopamine and serotonin Ach/dopamine balance

Activity Clearance in acute (ortho, neuro, pulm, general appearance, skin conditions)

Activity Clearance •Ortho: WB and ROM status, post op precautions •Neuro: craniotomy precautions, bone flap, spine clearance, brace/activity orders •Pulm: chest tubes, vent settings •General appearance (lines and tubes) and mental status •Skin considerations

Factors influencing life expectancy are:

Age at onset Level of neurological injury Extent of neurological injury

Exercise Vital Signs Criteria for terminating mobilization Alertness/Agitation and Patient symptoms: •Patient sedation or coma - RASS ≤ ___ •Patient agitation requiring addition or escalation of sedative medication; RASS >____ •Patient reports _______ •Patient _____

Alertness/Agitation and Patient symptoms: •Patient sedation or coma - RASS ≤ −3 •Patient agitation requiring addition or escalation of sedative medication; RASS >2 •Patient reports intolerable DOE •Patient refusal

Lateropulsion:

An involuntary movement of the body or turning of the gait toward one side; seen principally with unilateral infarction of a cerebellar

Which of the following is the MOST important consideration when deciding appropriateness of therapeutic activity? A.Amount of time required B.Amount of assistance required C.Risk to benefit ratio D.Amount of equipment needed

C???

Excess DF at MSt and/or TSt

Ankle collapses into >5° DF at MSt and/or >10° DF at TSt knee flexion or hip flexion contracture Analysis: Examine ROM and PF strength and hip/knee flexion contractures

Excess PF at MSt and/or TSt

Ankle fails to achieve 5° DF at MSt and/or 10° DF at TSt intentional to avoid ankle/knee collapse if PF and VASTII are weak Analysis: Examine ROM and tone of PF contracture and PF tone; strength of calf and vastii, evaluate if intentional due to dual areas of weakness

____ •usually require a longer length of stay during inpatient rehab compared to people with other types of SCI clinical syndromes

Anterior cord syndrome

slowly conducting

Anterolateral spinothalamic

•Which medication works well for tremor? PD

Anticholinergics and amantadine

Fatigue Management GBS

Appropriate overall exercise program Energy conservation education

TBI: If cant speak, getting to do auto things can release some of those frustrations

Don't have to originate the thought, it just has to flow (count with me: 1,2, 3, ...) Happy birthday

pons, internal ear, and cerebellum

Basilar artery

•Resistance Training MS

Better tolerated if done intermittently throughout the day, alternating upper and lower body •Increase resistance 2-5% once 15 reps is consistently achieved •Prioritize large, multi-joint muscle groups

H&Y 3:

Bilateral dz: mild to mod disability. Impaired postural reflexes. Physically independent

H&Y 2

Bilateral or midline involvmnt WITHOUT impairement of balance

Immune Component MS

Body responds to a trigger that instructs the immune system to "attack" the CNS and optic nerves. •T-cells cause inflammation (unknown reason for activation) --> T regulatory cells are supposed to decrease inflammation, but do not function correctly --> Cytotoxic T cells attack and destroy cells --> Activate B cells •B cells produce antibodies and stimulate other proteins that cause damage

Often this is most disabling motor symptom. Why?

Bradykinesia - cant do anything quick enough to do anything

Differential Diagnosis GBS

Brainstem stroke or glioma • Spinal cord injury •Hemorrhage or abscess • Acute myelopathy •Space occupying lesions • •Acute transverse myelitis • Peripheral neuropathy •GBS subtypes • •Post-rabies vaccine • •Heavy metals, biological toxins, drug intoxication Neuromuscular transmission •Myasthenia gravis • •Biological/industrial toxins • Muscle disorders •Hypokalemia, •Hypophosphatemia, •Inflammatory myopathy, •Acute rhabdomyolyses, •Trichinosis

____ is often one of the first indicators that spinal shock is resolving.

Bulbocavernous reflex

Custom hinged AFO for knee control.

By adjusting the position of the ankle, set in 5 degrees dorsiflexion, that limits knee hyperextension, while an ankle set in 5 degrees plantarflexion decreases the flexor moment and stabilizes the knee during midstance.

A 56-year-old patient with amyotrophic lateral sclerosis reports mild to moderate right shoulder pain that has been getting worse over the past 3 weeks. The strength of the shoulder musculature is 4/5. Which of the following is the MOST appropriate intervention at this point in time? a. Performing heavy eccentric exercises to maintain stabilization b. Providing the patient with a sling to allow his shoulder to rest c. Managing pain and advancing to moderate resistance exercises d. Using modalities for pain relief

C

Why loss of vibration, proprioception, touch and pain? Which tract is affected? GBS

Dorsal column medial lemniscal system. Why is it affected? it is large, rapidly conducting

rapidly conducting

Dorsal column-Medial lemniscal

Transient ischemic attack (TIA)***: Following the attack, there is

no evidence of residual brain damage or dysfunction

C1-2

C1-2 SCM, upper trap

Low cervical- Level of cord injury and the degree of respiratory dysfunction

C3-C6): vital capacity is 20% of normal, cough is weak and ineffective

•After SCI, hypothalamus can

no longer control cutaneous blood flow or level of sweating

Lateral medullary (Wallenburg's) syndrome: Dysphagia and dysphonia: paralysis of palatal and laryngeal muscles, diminished gag reflex

CN IX and CN X or nuclei IL to lesion

•Most common cause of disability among adults in the US

CVA

largest group admitted to inpatient rehabilitation hospitals

CVA's

AMAN-- •Most preceded by ____ •Sensory nerves are _____ • - acute ______ •Motor axonal______ •Auto-immune response ______ •Seasonal and recovery _____

Campylobacter jejuni not affected paralysis and respiratory failure loss and conduction block at nodes of Ranvier directed against the axoplasm of peripheral nerves can be rapid, or may be slow

Ideomotor apraxia:

Cannot voluntarily perform a learned task when given the necessary objects. For instance, if given a screwdriver, the person may try to write with it as if it were a pen.

PPS: ________ training usually more effective than ______

Cardiopulmonary strengthening •Frequent breaks

HIP Adduction

Cause: hip adductor spasticity/contracture Excess contralateral pelvic drop Analysis: examine tone of hip flexors and adductors; mm str of hip abductors Scissoring- CP, stroke

Repeated sensory stimulation:

EMPI found that wearing a sensory glove with electrical stim coming to the glove increased patient's awareness and sensation in that hand, even during the chronic phase of recovery.

Bilateral Vestibular Loss

Clinical Presentation •difficulty walking especially in dark, prior history of severe infection requiring IV antibiotics Pathology •Loss of vestibular function due to damage to hair cells •Ototoxic Medications •aminoglycosides: gentamicin, etc. •Idiopathic age related •Idiopathic familial •Meningitis (because treated with antibiotics that are ototoxic)

Lab values

Collaborate with interprofessional team Use symptoms-based approach when determining appropriateness of activity

Ipsilateral trunk lean- reference limb STANCE

Compensation for ipsilateral hip abductor weakness ipsilateral hip joint pain (takes pressure off muscles- often mixed up and think CL but often IL) ITB tightness or scoliosis Analysis: examine ipsilateral glut med str; hip pain and ipsilateral ITB tightness and for trunk ROM

The 3 regulatory mechanisms of cerebral blood flow management:

Concentration of co2 and o2 pH in blood neurogenic

Infections: Management: Considered a

Considered a Medical Emergency

Purulent:

Containing, discharging, or causing the production of pus.

MFS: •Usually affects ___ muscles first and presents with:

EYE •Opthalmoplegia •Ataxia •Areflexia

2nd degree heart block & s/s

Contraindications

3rd degree heart block

Contraindications

New onset AFib, Aflutter

Contraindications

New onset brad/tach w/ hemodynamic compromise

Contraindications

PVC > 6 in a row

Contraindications

ST Segment Elevation/Depression

Contraindications

Sustained VTach

Contraindications

VFib

Contraindications

•Treating elevated ICP:

•Sedating meds • •Ventricular drainage •Osmotherapy •Hypothermia •Surgical decompression •Barbituates

AIDP vs AMAN: Cranial N involvement Sensory N involvement Autonomic N involvement

Cranial N involvement AIDP: Frequent AMAN: Rare Sensory N involvement AIDP: Frequent AMAN: None Autonomic N involvement AIDP: Frequent AMAN: Rare

Neuromuscular System- acute

Critical Illness Polyneuropathy (CIPN) •Acute motor axonal neuropathy •Severe Weakness and difficulty weaning from vent •Appears to be associated with sepsis, multi-organ failure and SIRS •Recovery can take weeks to months

Lateral medullary (Wallenburg's) syndrome: Sensory impairment of ipsilateral UE, trunk or LE

Cuneate and gracile nuclei IL to lesion

Strength MS FITT

Frequency: 2-3x/wk Intensity: 1-3 sets, 8-15 reps at 60-80% 1 rep-max Type: body resistance, free weights, weight machines, bands T(Duration): Perhaps intermittent during day, alternating upper and lower body

Aerobic FITT MS

Frequency: 3x/wk Intensity: Mod - 50-65% or 60-75% VO2 max Type: walking, biking, swimming, water aerobics T(Duration): 30 minutes/session or 3x10 minute sessions

TBI **Secondary impairments:

DVT HO Pressure ulcer Pneumonia Chronic pain Contractures Decreased endurance Muscle atrophy Fracture Peripheral nerve damage

TBI •Secondary Impairments

DVT, pressure ulcer, pneumonia, chronic pain, decreased endurance, muscle atrophy, fracture, peripheral nerve damage, urinary and bowel incontinence, GI difficulties, genitourinary problems, respiratory problems

red blood cell mass

Decreased

total blood volume

Decreased

Lateral medullary (Wallenburg's) syndrome: IL to lesion

Decreased pain and temp in face Cerebellar ataxia; gait and limb ataxia Vertigo, nausea, vomiting Nystagmus (direction changing), towards side of lesion more common) Horners Dysphagia and dysphonia: Sensory impairment of ipsilateral UE, trunk or LE

Musculoskeletal/Neuromuscular PT in GBS

Degree of weakness proportional to number of motor neurons affected. Can only strengthen what they have - exercise will not hasten nerve remyelination - a graded progression is required! •Begin with fewer repetitions, frequent short exercise periods •PROM--AAROM--AROM—RROM •PNF patterns/techniques may work High risk for contractures

Lateral medullary (Wallenburg's) syndrome: Decreased pain and temp in face

Descending tract and nucleus of CN V IL to lesion

=orthostatic hypotension is often experienced during early transitions to a more upright posture

Disrupted balance between sympathetic and parasympathetic input

motor in CVA: •____ muscles exhibit greater strength deficits than ____

Distal more deficits than proximal

Rancho Los Amigos Level of Cognitive functioning 4

Does not discriminate among persons or objects; is unable to cooperate directly with tx efforts. Verbalizations frequently are incoherent and/ confabulation may be present. Gross attention to env is very brief; selective attention is often nonexistent. Pt lacks short- and long-term recall

Phase 3. Mid Stance

Dynamic stability over the plantigrade foot

Bulbar Clinical Impairments ALS: Dysphagia 2 others

Dysphagia: •(chewing and swallowing) weakness causes increased aspiration risk: food can't move into esophagus, liquids regurgitate into nose, cough reflex is weak/absent. •Uncoordinated closure of epiglottis allows liquids or solids to pass into the larynx •Choking and slowed eating place patients at risk for less than optimal fluid and caloric intake: often develop cachexia •Sialorrhea also commonly develops •Pseudobulbar affect: poor or pathological emotional control. Seen in individuals with spastic bulbar palsy. •Spontaneous crying or laughing in the absence of emotional triggers. Occurs in up to 50% of patients

•Patient Controlled Analgesia (PCA),

Epidural pump

In-clinic POC Recommendations MS: •During stable periods:

Every 3-6 months for modifications to exercise/activity recommendations, recheck status, motivate to continue good behaviors

bppv exam

Examination •, assess neck ROM •Dix-Hallpike/Side-lying test (vertical canals) •Roll test (horizontal canals) Abnormal Test Results •History of motion provoked nystagmus •Positive Dix-Hallpike (Roll test) Recommended Treatment: •CRT*, habituation, balance/gait re-education

Unilateral Vestibular Loss

Examination •Nystagmus examination •Clinical VOR testing (Head Impulse testing) •After Head Shake •Gait/balance Abnormal Test Results •History of vestibular crisis (neuritis/labyrinthitis) •Positive corrective saccades with unilateral head thrust (HIT) •After Head Shake Nystagmus and direction-fixed spontaneous/positional nystagmus •Rotation during Fukuda (typically not perceived) •Postural instability during CTSIB 5/6 (vestibular trials) •DVA-Dynamic visual acuity (>3 line loss) Recommended Treatment: •Vestibular Adaptation*, habituation, balance/gait re-education

Clinical Testing for Bilateral Hypofunction

Examination Tools: •HIT •Slow VOR testing •CTSIB/SOT •Gait Abnormal Tests: •Hx consistent with severe infection w/antibiotics •Positive bilateral corrective saccades with head thrust testing at even slow speeds (HIT) •Often fall on Fukada or profound rotation •Free falls on CTSIB 5/6 (vestibular conditions) •DVA >5 line loss Severely impaired gait, profound with eyes closed

Excess inversion or eversion in Stance or swing

Excessive inversion: reduced activity of evertors; primitive extensor pattern. Excessive eversion: reduced activity/strength of invertors; primitive flexor pattern Analysis: Examine strength and timing of LE mvmt and tone; and for contractures

MG •Class III:

Eye mm weakness, mod weakness of other mms •IIIa: predominantly limb or axial mm •IIIb: predominantly bulbar/respiratory

GBS OM's

FIST Berg- even if score

DIX-HALLPIKE TESTING

FOR Benign Paroxysmal Positional Vertigo (BPPV) Maneuver - stay in position 60 seconds Abnormal Test - Latency (3-5 sec) - c/o Dizziness with Nystagmus observed - Fatigues within 60 sec. - Habituates across repetition

Intermediate

Fair sitting balance and trunk control Achieves close to neutral posture Needs postural supports

Rancho Los Amigos Level of Cognitive functioning 6

Follows simple directions consistently and shows carryover for relearned tasks. but they are appropriate to the situation. Past memories show more depth and detail than recent memories VI- might be able to remember fam names

MS oM's

Four square step test, ABC

FiO2 =

Fraction of Inspired O2; amount of O2 in atmosphere •Room air's FiO2 is 21%. •In healthy adults, this is enough to maintain an SpO2 of >94%. •Most ICU patients cannot maintain an SpO2 >90% w/o supplemental O2.

One of the most dramatic neurologic emergencies.

GBS

•A broad spectrum of inflammatory demyelinating polyradiculoneuropathies have been identified (last 15-20+yrs)•_ ___ is the most frequent of these.

GBS

ICP monitored for:

GC≤8, systolic BP < 90 mmHg, age >40 yo

If somebody has no retinal slip we say they have perfect____________

Gain*

WHO Tumor Classification: •Primary Brain Tumors (cancer originating in the brain)

Gliomas (tumors of the supportive tissue) •Astrocytomas (star-shaped glial cells) •Oligodendrogliomas (slow-growing but progressive) •Ependymomas (tumorous cells that line the ventricles) •Medulloblastomas (malignant embryonal tumors)- mostly kids (cerebellum again)

Functional Loops

Goal directed behavior - uses laws of physics and natural world to make decisions (red light) Social behavior - sifts relevant/irrelevant and manages some social inhibition Emotional - facial expressions and emotion link; reward-seeking Oculomotor - pro-saccades Motor - overcoming inertia, modifying movements, postural awareness

Basic

Good sitting balance, hands-free sitter Achieves neutral posture without support No additional postural supports needed

•1.Smooth pursuit (<.5 - 1 hz)

Head fixed, eyes tracking object below 1-2 Hz •Look for: saccadic interruptions, cogwheeling

Secondary/Metastatic Brain Tumors: •General signs and symptoms

Headache: •New •Abnormal (different in type or severity) •Interrupts sleep •Worsens with walking •Elicited by postural changes, coughing, exercise •Associated with nausea/vomiting, visual disturbance, or other focal neurological signs •Seizure •Altered Mental Status •Transient visual loss (papilledema)

Ex VS: Heart Rate: •>___% Age-predicted Max Heart Rate (APMHR) •> ____% decrease in resting HR •< ____ beats/minute; >____ beats/minute •New onset _____ •New ______ medication •New ____ by ECG or cardiac enzymes

Heart Rate: •>70% Age-predicted Max Heart Rate (APMHR) •> 20% decrease in resting HR •< 40 beats/minute; > 130 beats/minute •New onset dysrhythmia •New anti-arrhythmia medication •New MI by ECG or cardiac enzymes

Respiratory Care ALS

High risk for respiratory tract infection: •1. Pneumococcal and influenza vaccinations •2. Prevention of aspiration •3. Effective oral and pulmonary secretion mgmt •When VC (vital capacity) decreases to 50% of predicted, positive pressure NIV (non invasive ventilation) is recommended.

LowerExtremity- one of strongest componenet flexion oblig synergy

Hip flexion* inversion

Alertness TBI

How do you assess them? (Rancho IV) •Why is it important? Arousal, attention, cognition= all parts of orientation In lab tx'ing TBI levels Might physically have to sit them up or stand them up How assess sensation on rancho 4- pinch arm, pinch and no rxn- it appears no pain perception

Acute Polio Recovery Mechanisms**

Increased recruitment of the giant motor units recovered neurons develop terminal axon sprouts to reinnervate orphaned muscle fibers. A single motor neuron is estimated to reinnervate up to five or more times its normal complement of muscle fibers, creating giant motor units. ***More difficulty grading force production and movements denervation hypertrophy

blood fibrinogen

Increased

GBS: What are some signs you are doing to much with your patient?

Increased muscle soreness Increased dependence on ventilator Increasing sensory loss

Terminal Stance:

Interval: second half of SLS (single limb support). This phase complete SLS. It begins with heel rise and continues until the other foot strikes the ground. Body weight moves ahead of the forefoot throughout this phase.

Initial Swing interval

Interval: the first phase of swing is approximately 1/3 of the swing period. It begins as the foot is lifted from the floor and ends when the swinging foot is opposite the stance foot

MG Class V:

Intubation needed to maintain airway

UMN syndrome: trunk

Lateral flexion with concavity Rotation Rotators Int/ext obliques

Difficulty processing verbal commands

L

Disorganized

L

Perseveration

L

highly distractible,

L

processing delays,

L

What level is a spinal tap preformed at?

L3/4 or L4/5

LONGER TERM (Neurologically stable x___mos) GBS PT

LONGER TERM (Neurologically stable x 3 mos) •Strengthening - can be more aggressive •Aerobic exercise •Maintain flexibility Fatigue management

Lab Trends •Consider when _____ •Potential ______ •Recent _____ •Electrolyte panels may change with ______ •Up to ___% with acute MI have elevated troponin within ____ hours of chest pain •Cardiac enzyme (troponin) level will _____but _____

Lab Trends •Consider when the specimen was drawn •Potential drug interactions •Recent meals •Electrolyte panels may change with infusions, medications, and diet •Up to 80% with acute MI have elevated troponin within 3 hours of chest pain •Cardiac enzyme (troponin) level will not drop suddenly but decrease over time

IL wallenb

Lateropulsion towards side of lesion

Toes or forefoot contact at IC

Leg length discrepancy DF weakness Excessive knee flexion when combined with any impairment that limits ability to achieve neutral ankle Analyse: Examine ROM, leg length, hip/knee/ankle contractures, muscle tone, timing of PF. Examine pretibial strength, heel pain

•Which are primary medications to treat dopamine loss?

Levodopa/carbidopa AND dopamine agonists

Air-stirrup can provide

M/L stability at the subtalar joint while allowing dorsiflexion and plantarflexion

•Neuroprotective AND neuroregenerative!!!

MS

•Second-ranked chronic condition in direct all—cause medical costs (behind CHF)

MS

•Ocrevus

MS drug •Antibody targeting CD20-positive B lymphocytes •CIS, RRMS, SPMS, ***PPMS

Berg Balance (BBS)

Max score 56 <45 Fall risk 41-56 low fall risk 21-40 medium/moderate fall risk 0-20 high fall risk

Exercise Vital Signs Criteria for terminating mobilization session: Mechanical Ventilation: •FIO2 ≥ ___ •PEEP ≥ ___ •Patient-ventilator ______ •MV mode change to ______ •____ airway

Mechanical Ventilation: •FIO2 ≥ 0.60 •PEEP ≥ 10 •Patient-ventilator asynchrony •MV mode change to assist-control •Tenuous airway

Brain Tumor Rehabilitation: •Brain tumors present similar to other CNS disorders •How does rehabilitation for this population differ? •Which psychosocial factors likely impact the POC? •How do you prognosticate outcome and write realistic goals when you have limited experience? •What impact do you suppose radiation and chemotherapy have on rehabilitation? How might you modify treatment to address those factors?

Medical management, progression, prognosis, living situation, personal goals

Expanded Disability Status Scale (EDSS) -

Most ppl 0 to 5.0 (indep gait), about 1/3 are 6.0 to 8.5 [MS] •8 Functional Systems - each graded 0 to 5 or 6: •Pyramidal •Cerebellar •Brainstem •Sensory •Bowel and bladder •Visual •Cerebral •"Other"

•Most common cause for non-traumatic disability in young adults

Multiple Sclerosis

•What systems are affected following SCI (direct impairment)?

Musculoskeletal system, neuromuscular system, cardiopulmonary, integumentary, gastrointestinal, genitourinary, sensory Biggest indirect psychosocial----long-term

Westmead

Must get 12/12 correct 3 days in a row. PTA is considered to be over on the first of the 3 days.

Prognosis MS

No Cure Aim to: •Slow/change disease course •Treat exacerbations •Manage symptoms •Improve Function and Safety •Support emotional health

•Often more debilitating in the long run

Neurobehavioral Impairments: •Low frustration tolerance • • aggressive disinhibition •Apathy • •Mental inflexibility •Impulsivity

Noninvasive ventilation (NIV): ALS

Noninvasive ventilation (NIV) refers to the administration of ventilatory support without using an invasive artificial airway (endotracheal tube or tracheostomy tube). The use of noninvasive ventilation has markedly increased over the past two decades, and noninvasive ventilation has now become an integral tool in the management of both acute and chronic respiratory failure, in both the home setting and in the critical care unit. Noninvasive ventilation has been used as a replacement for invasive ventilation but its flexibility also allows it to be a valuable complement in patient management. Continuous positive airway pressure.

Foot flat contact at IC

PF contracture Weak DF Knee flexion contracture Analysis: ROM at ankle and knee; strength of pretibial mm

•What Can cause Central Pathology? vestibular

PICA, IACA, anything that impacts medulla pons area

Infections: If their presentation can vary so greatly, how can you prepare to treat this population?

Observe/Guide if you must Assess abilities/needs Use what they have/work towards their goals

If an injury occurs below the superior colliculus, what is the only cranial nerve preserved?

Oculomotor*-

Acute vs Chronic Considerations •Understand patients' diagnoses and symptoms •Examples: •Anemia •Did the patient sustain a trauma or undergo sx? •What is their usual Hemoglobin (Hgb) and Hematocrit (Hct) levels? •Cancer •Why do they have an elevated white count? Why does that differ from other causes? •

Often 30 10 40- those all thousands (WBC count) Normal 10 or below, and 30 is crazy high Liekly white cell count been high for a long itme Could have leurk and v low count- so don't spread anything

H&Y: Often see

Often see 3 and 4 - if could get 2.5 and below would make a big difference

•Your patient comes to your clinic for an evaluation. The order says "Eval and treat, unilateral vestibular hypofunction from labyrinthitis March 8th." • •What questions do you ask?

On meds- helps, but still taking it- reschedule for day or 2 later after come off meds bc wont get true pic of vestib system if still on vestib suppressants Educ- Prevents brain from recovery, just hide sy's- now dizziness ok , unless brain gets it and feels error it wont get better-

Front-wheel drive: p neg

Optimal for traversing obstacles Closer proximity to tables neg: •Back end moves first and care must be taken to ensure sufficient posterior clearance

•Theories PPS etiology MUSCLE:

Overuse and fatigue of the already weakened muscles

Stroke balance testing

PASS, FIST, BERG, POMA, FR, TUG, CTSIB

Paralysis or paresis of the___ AND ___ mm results in a paradoxical breathing pattern.

Paralysis or paresis of the scalenes and intercostal mm results in a paradoxical breathing pattern. Flattening of upper chest wall, decreased chest wall expansion, and a dominant epigastric rise during inspiration. Inefficient and fatiguing.

Management

Patients lived 7.5 months longer if attending a multidisciplinary clinic that specialized in ALS

C6-8

Pec major, pec minor, serratus

Wound Vac

Provide negative pressure (various settings-continuous or not). Helps with debridement, removes interstitial edema, decreased local edema, increases blood flow Disconnect power cord to battery. Check WB status Try to avoid clamping and disconnecting the hose. Watch output

DVT:

Pitting edema confined to the symptomatic leg 100% suspected with homan's sx right bc wells

Management of Chest Tubes

Place container upright, below incision level, kink-free. Ask MD/RN if cleared to disconnect suction tube from container. Place container on IV tower, w/c or hand hold. Use gait belt if appropriate. Notify RN if tube is pulled out. Safety pin to gown or it WILL pop off- suction, lose drainage - MAKE SURE safety pin Drainer- collects in different increments- do not knock it over

Complex

Poor sitting balance Unable to achieve neutral posture Needs custom supports

AFib

Precautions

Atrial Flutter

Precautions

PVC <6/min

Precautions

Premature Atrial Contraction

Precautions

Supraventricular Tachycardia

Precautions

Precautions •Universal Precautions (____) •Contact Precautions (____) •i.e. •Enteric Precautions (______) i.e. •Droplet Precautions (___) i.e •Airborne Precautions (____) i.e.

Precautions •Universal Precautions (hand sanitizer) •Contact Precautions (gown and glove) •MRSA, VRE, RSV •Enteric Precautions (gown, glove, soap and water) •Clostridium Difficil (C-Diff) •Droplet Precautions (mask) •influenza, pertussis (whooping cough), mumps, + neutropenia •Airborne Precautions (negative pressure room, N95 mask or PAPR respirator) •tuberculosis, measles, chickenpox, disseminated herpes zoster

Drag at Swing

Pretibial weakness PF spasticity/contracture Inadequate knee/hip flexion Analysis: Examine ROM of ankle, knee, hip; strength of mm critical for limb clearance

Inferior oblique muscle:

Primary action is extorsion (external rotation); secondary action is elevation; tertiary action is abduction (i.e. it extorts the eye and moves it upward and outwards). The field of maximal inferior oblique elevation is in the adducted position. The inferior oblique muscle is the only muscle that is capable of elevating the eye when it is in a fully adducted position.

Bilateral use of UE even with hand over hand to help is beneficial.

Quadruped to get UE weight bearing even if elbow has to be supported to accepted weight.

Rigidity of thought

R

Synthesizing information

R

Unrealistic Poor insight

R

Visual-perceptual impairments

R

agnosia,

R

fluctuations in performance

R

grasping idea of task

R

impaired body image,

R

problem solving

R

rancho 1

ROM (Prevent contractures), tone, integ (bed sores), vitals

rancho 4

ROM, MMT, LT/ST memory, stereoagnosis- if cant do rom/mmt bc cant make sense- ..... Also start assessing into rancho 5

Primary Injury TBI

Rapid acceleration/ deceleration of the brain creating cortical disruption (CC and DAI)

Rancho Los Amigos Level of Cognitive functioning 8

Recall and integrate past and recent events, is aware of and responsive to env. May continue to show decreased ability relative to premorbid abilities, abstract reasoning, tolerance for stress, and judgment in emergencies or unusual circumstances

Respiratory System: •respiratory rate •ventilation/perfusion (VQ) mismatch •O2/CO2 balance •respiratory movement and cough •Fluid ____ •Dehydration leads to ______ •____ atelectasis •______ of pneumonia

Respiratory System •Increased •Increased •Changes in O2/CO2 balance •Decreased respiratory movement and cough •Fluid stasis •Dehydration leads to thick secretions •Increased atelectasis •Increased risk of pneumonia

Rehabilitation Paradigm MS

Rehab management - mobility, ADLs, speech/swallowing, cognition, roles •Motivation and Education •Self-efficacy and self-management - resources •Skills to adapt and compensate •Return function after exacerbation •Plan and manage "new normal" when don't return completely to baseline

Exercise Vital Signs Criteria for terminating mobilization Respiratory Rate: < ____ breaths/minute; > ____breaths/minute

Respiratory Rate: < 5 breaths/minute; > 40 breaths/minute

depression CVA

Seen with lesions in left front lobe (acute) seen with lesions in right parietal lobes (subacute) average time of significant depression lasts 7-8 mos Depression occurs in both mildly and severely involved patients and thus is not significantly related to the degree of motor impairment (DIRECT IMPAIRMENT of CVA).

MS: ____changes are most common symptom and, often, the first symptom experienced

Sensory paresthesia, dysesthesia, position sense, vibration

AVM:

Sudden and severe cerebral bleeding can result in death within hours, because intracranial pressures rise rapidly and adjacent cortical tissues are compressed or displaced as in brainstem herniation

•Sex, Gender, and Gender Identity

Sex specific ranges change when individuals receive hormone replacement therapy. If H replacement, treat as gender of identity If dn receive tx for it, have to use biology but still address

visuospatial impairment has been identified in patients with PD and correlated with lower scores in mobility.

Some patients are unable to perceive the upright or vertical position, which may indicate an abnormality in processing o vestibular, visual, and proprioceptive information contributing to balance

Toe clawing in Stance

Spasticity of toe flexors Excessive activation of toe flexors to compensate for weak gastroc/soleus PF grasp reflex Analysis: Examine tone of toe flexors, strength of PF, primitive reflexes

Early heel rise at MSt

Spasticity or contracture of PF Analysis: Examine ROM and tone for PF spasticity/contractures

Electrodiagnostics diagnosic testing MG

Stimulating a nerve-muscle motor unit with short sequences of rapid, regular electrical impulses, before and after exercising the motor unit, the fatigability of the muscle can be measured. "repetitive nerve stimulation test".

Middle Cerebral Artery Syndrome

Supplies: •(frontal, temporal, parietal lobes) •Subcortical structures •Internal capsule •Corona radiata •Globus pallidus •Caudate nucleus •Putamen

TBI: Surround patient with

Surround patient with familiar objects (smells, music, pictures) without overstimulating

•Signs the patient needs supplemental O2:

Tachycardia, Shortness of Breath (SOB), Confusion, Cyanosis

SIMV:

Synchronized intermittent mandatory ventilation. Not all spontaneous breaths are assisted, leaving pt to draw some breaths on their own. If SIMV mode is set at respiratory rate of 10 bpm, she will receive a breath roughly once very six seconds. She can breathe on her own in between the machine assisted breaths. (+) helps preserve the strength of the resp mm, decreases the risk of hyperventilation and barotrauma, and facilitates weaning. Still a dialed in rate, can breathe above the rate, but never below the rate.. Still a dialed in volume and FiO2. ---can also have PEEP or pressure support.

Primary muscles of expiration are abdominals and internal intercostals.:

T5-T12: abdominals: intrathoracic pressure for effective respiration. Support viscera and maintain position of diaphragm. Also push diaphragm up during forced expiration With paralysis of abdominals this support is lost, causing the diaphragm to assume an unusually low position in the chest. This low position and lack of abdominal pressure to move the diaphragm up during forced expiration results in a decreased expiratory reserve volume and impaired cough effectiveness

•Leading cause of injury-related death and disability in the US

TBI:

Thymic abnormalities are clearly associated with myasthenia gravis but the nature of the association is uncertain.

Ten percent of patients with myasthenia gravis have a thymic tumor and 70% have hyperplastic changes (germinal centers) that indicate an active immune response. These are areas within lymphoid tissue where B-cells interact with helper T-cells to produce antibodies. Because the thymus is the central organ for immunological self-tolerance, it is reasonable to suspect that thymic abnormalities cause the breakdown in tolerance that causes an immune-mediated attack on AChR in myasthenia gravis. The thymus contains all the necessary elements for the pathogenesis of myasthenia gravis: myoid cells that express the AChR antigen, antigen presenting cells, and immunocompetent T-cells. Thymus tissue from patients with myasthenia gravis produces AChR antibodies when implanted into immunodeficient mice. However, it is still uncertain whether the role of the thymus in the pathogenesis of myasthenia gravis is primary or secondary. Most thymic tumors in patients with myasthenia gravis are benign, well-differentiated and encapsulated, and can be removed completely at surgery.

Pre swing is:

Terminal double limb support initiated by floor contact of other limb

Arm cradling in CVA

The more affected UE cradles and lfits the less affected UE to 90 degrees, the arm ismoved into positions of horization abd and add. Active trunk rotation is combined with the arm movements.

Apraxia Causes, incidence, and risk factors

The most common causes of acquired apraxia are: 1 Brain tumor 2 Condition that causes gradual worsening of the brain and nervous system (neurodegenerative illness) 3 Dementia 4 Stroke 5 Traumatic brain injury

Pathology GBS

The spinal roots and peripheral nerves are infiltrated with macrophages and T-lymphocytes

Initial swing:

The thigh begins to advance as the foot comes up off the floor

What happens to people as they try to increase their walking speed?

Their tone increases and they have higher risk of falling and my not increase their speed. The anticipation of not getting across the street in time also increases tone making increasing cadence more unsafe.

EFFECTS OF SUPPLEMENTAL OXYGEN — ALS

There have been many mechanisms postulated to explain why patients with COPD sometimes develop hypercapnia when given supplemental oxygen. It had been thought that patients with COPD rely on their hypoxic ventilatory drive due to a blunted sensitivity to CO2 (ie, pH), and that hypercapnia in this setting resulted from "removal" of hypoxic drive with a consequent reduction in alveolar ventilation. However, empiric data have been difficult to reconcile with this theory. It is also noteworthy that one report described different ventilatory responses to oxygen in the same patients when they were stable compared to responses obtained during episodes of acute respiratory insufficiency

Bridge to Transplant VAD

Thoratec HeartWare CardioWest Total Artificial Heart (SynCardia) Thoratec PVAD

Foot/ankle UMN syndrome:

Toes claw Toes curl Ext hallucis longus; peroneus longus

External Pacemaker

Used for temporary correction of heart rhythm: bradycardia, tachycardia, arrhythmia, etc. OK to mobilize with the pacemaker. Once removed, mobilize > 60 minutes later. Make sure its secure Once removed give about 60 mins when mobilized when removed pacer

•cerebellum and medulla

Vertebral arteries

Some people require double upright/dual channel.

Very outdated. However still may be used for people who cannot tolerate plastic AFO's owing to sensory impairments, girth fluctuations, or diabetic neuropathy or who require additional controls.

Which diagnosis would most likely have impaired gain?

Vestibular neuritis* Vestibular labyrinthitis*

Lateral medullary (Wallenburg's) syndrome: Nystagmus (direction changing), towards side of lesion more common)

Vestibular nuclei and connections IL to lesion

Lateral medullary (Wallenburg's) syndrome: Vertigo, nausea, vomiting

Vestibular nuclei and connections IL to lesion

1.Nociceptive-

Visceral (and renal calculi/osteoporosis) opioids

Other Possible Factors: MS

Vitamin D deficits Smoking Obesity - especially in childhood and adolescence Viruses

•What impact could a field cut have on functional recovery?

Walking and bumping shoulder, catching toe, return to driving, negotiating a power w/c., etc

____ showed greater concurrent validity (TBI used ____). Not as much info from O-log. O-log kept reporting patients were out of PTA in TBI study but clearly were not. O-log you are allowed to cue, O-log doesn't expect a perfect score

Westmead O-log

•Why might you want to work on compensation vs. recovery? CVA

Years ago, patient's suffering stroke were in the hospital 30-60 days. Now lengths of stay have decreased to 14-21 days in some settings. Our goal is to get patients functionally safe to return home: I have 2 weeks instead of 8 weeks----I need to teach them to transfer safely and often that is compensating by using the good side and almost "dragging" the impaired side along for the ride. In outpatient, or in less involved clients, I always shoot for recovery.. Even with severely impaired folks I start with recovery, closer to discharge I train the patient and family how to do what they HAVE to do safely.

Brain Abscess Symptoms/Treatment

]•Site and size dependent - 3 common symptoms --> Intracranial pressure --> Focal neuro deficits --> Fever [Only about 50% of individuals with a brain abscess will demonstrated the triad of symptoms listed above] •Altered level of consciousness ~50% •Treatment -antibiotic therapy -surgical excision and/or drainage [Common side effects post treatment can include: - seizures, hemiparesis, disorders of speech and language]

SCI renal calculi and osteoporosis:

changes in calcium metabolism following SCI lead to osteoporosis below level of lesion and development of renal calculi. Normally, there is a dynamic balance between the bone resorption activity of osteoclasts and the role of osteoblasts in laying down new bone. following SCI, there is a net loss of bone mass because the rate of resorption is greater than the rate of new bone formation consequently, there is a greater susceptibility to fracture as result of resorption there are large concentrations of calcium present in the urinary system, predisposition to stone formation highest incidence of bone mass changes and hypercalciuria occurs during the first 6 months immobility and lack of stress placed on skeletal system thru dynamic weightbearing activities are accepted as major contributing factors

AD is more common in the

chronic stage of recovery (3-6 mos post injury)

thumb and fingers UMN syndrome:

clenched fist thumb adducted in palm Flexor digitorum profundus/sublimis, adductor pollicis brevis, flexor pollicis brevis

Direct impairments: TBI

cognition, attention, appropriateness, follow commands, task planning, distractible, sensation, strength, tone, motor control, coordination, memory, communication, vision, pain

DAI may be severe enough to cause _____ and correlates with _______

coma less clinical recovery

rancho 3

command following, AAROM, getting to express agitation, playing music, smells- things to make more agitated (Once aggit done want to escalate)

PP sequalae-

compensate and now degenerative knees- things that follow Disuse atrophy, pain... - all that labeled sequelae-

Circumduction:

compensation for weak hip flexors or for inability to shorten leg for limb clearance Analysis: strength (str) of hip flexors, knee flexors, and ankle DF; ROM in hip and knee flexion, and ankle DF and for abNormal extensor pattern Above knee amputations often see, stroke

Excess hip flexion Swing:

compensatory to assist with limb clearance if limb is functionally too long (if its need to clear the toes) flexion synergy during swing resulting in too much flexion analysis: examine for compensation, determine if ankle and knee of reference limb are achieving correct joint positions. Examine contralateral limb to determine if deviations are occurring on opposite side-could contribute to clearance problems on reference side

Upper Extremity function •With severe impairment, early on, •____ helps promote proximal stabilization •Reaching: (CVA)

compensatory training strategies and envir. adaptations should be considered to maximize function •Weight bearing on extended arm with stabilized hand _____ •Slide hand forward over table with cloth to ↓ friction

Cognitive TBI

concentration learning •Arousal •Attention Often have to be private room where dec other stimuli

ALS: •When NIV is no longer tolerated/effective,

decision needs to be made for invasive ventilation with tracheostomy or hospice care for late-stage respiratory symptoms

Indirect impairments: TBI

decreased ROM edema postural alignment in sitting/standing pain heart rate/rhythm (tachycardia) pressure ulcers

Indirect impairment TBI

decreased ROMedema postural alignment in sitting/standing pain heart rate/rhythm (tachycardia) pressure ulcers

Scoliosis

determine method to support scoliosis and obtain optimal trunk position because this will affect pelvic position

If see change in consciousness, change in performance one day to next-

did they sleep, did give sleeping pill, did give narcotic medication- if none of those, its an emergency Maybe need to go through a scan- common to have extension of stroke- we dont want disability more profound bc we miss something

Bradykinesia -

difficulty in maintaining movements, reduced amplitude, speed and range; Can be influenced by depression and rigidity; o

•Autoimmune disorder where an immune response is _____ (GBS)

directed towards unknown antigens triggered by the earlier infection.

Apraxia

disorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked, even though: 1 The request or command is understood 2 They are willing to perform the task 3 The muscles needed to perform the task work properly 4 The task may have already been learned

Sensation and skin integrity: WC

do they have impaired sensation? **pressure relief schedule Location and size of old wounds.

C8 and below exit in a

downward direction (do not emerge at corresponding vertebral level

UMN syndrome: Scapula

downward rotation

Both (bacterial and viral) meningitis can be transmitted through ____ during close contact such as kissing, sneezing or coughing on someone, but cannot be spread by _____

droplets of respiratory secretions only breathing the air where a person with meningitis has been

In contrast, pseudobulbar palsy describes impairment of function of cranial nerves

due to upper motor neuron lesions of the corticobulbar tracts in the mid-pons. For clinically evident dysfunction to occur, such lesions must be bilateral as these cranial nerve nuclei receive bilateral innervation.

the meninges are the

dura mater, the arachnoid mater, and the pia mater. Cerebrospinal fluid is located in the subarachnoid space between the arachnoid mater and the pia mater.

LIS: dys...

dysphonia

another VS

dyspnea

Levodopa

metabolic precursor of dopamine that can cross the blood-brain barrier and raise the level of dopamine in the BG. 99% of L-dopa is metabolized before reaching the brain, so Carbidopa allows a higher percentage of L-dopa to enter the CNS so lower doses of L-dopa can be used with fewer adverse side effects (Sinemet)=L-dopa + carbidopa, more and more Stalevo which combines COMT inhibitor entacapone with carbidopa/levodopa it alleviates bradykinesia and rigidity, not great on tremor and not at all on postural instability. The initial functional improvement is often dramatic and called the Honeymoon Period. a deterioration of the overall therapeutic effectiveness of L-dopa can be expected over time with increased motor complication of 10% per year. The therapeutic window is often 5-7 years before optimal benefit wears off. end-of-dose deterioration: worsening of symptoms during the expected time-frame of medication effectiveness. Random fluctuations in motor performance, termed "on-off" phenomenon (random fluctuations in motor performance) occur in 50% of pt's tx'd for more than 2 years. Dyskinesias often emerge in tandem with end-of-dose deterioration

Bulbar onset ALS is more common in

middle-aged women

Alterations in Tone CVA •Posturing is common with

mod to severe spasticity

TBI moderate servere -die

moderate 10-30% servere 5-25% -die: 35-60% 50,000-75,000/yr

Cerebral edema:

most common cause of death in acute stroke (MCA and internal carotid artery)

Astrocytomas -

most common primary brain tumors in adults and children •Typically originate in frontal lobe of adults and cerebellum in children 4 Grades: 1. Benign, low-grade 2. Diffuse, low-grade 3. Anaplastic, high-grade 4. Glioblatoma Multiforme, highly malignant (<33% live >1 year, <5% live > 5 years)

Lateral medullary (Wallenburg's) syndrome - vertebrobasilar: With gradual tx of associated HTN if present,

most patients survive and do not develop other posterior circulation strokes

GCS: TBI

motor score and pupillary reactivity predictors of poor recovery in mod/severe TBI

Guillain-Barré (GBS), or acute inflammatory demyelinating polyradiculoneuropathy (polyneuropathy), affects .... leading to.....

nerve roots and peripheral nerves leading to motor neuropathy, sensory changes, and flaccid paralysis.

Deteriorating stroke

neurological status deteriorates after admission to the hospital

•Acute encephalitis:

neurons that are vulnerable to specific viruses are invaded and undergo lysis.

ACA: *Because anterior communicating artery allows perfusion from either side,

occlusion proximal to this results in minimal deficit Distal lesions produce greater deficits.

50%

of people report their spasticity is problematic, negatively impacts their function

Seizures: in CVA

often have seizures in therapy, prepared to guard patient and contact nursing if needed.

Hospitalization and death as a result of TBI is most common in

older adults (65+ yo)

TBI: Most common in

older adults (>75 yo) followed by infants (0-4 yo)

When sitting in the w/c or in the bed you need to place the arm (CVA)

on a tray/trough to support it but to get it into the visual field. Also raise it slightly to prevent dependent edema.

Wobble in stance

or alternating spasticity of knee flexors and extensors Analysis: examine knee for proprioceptive impairments and spasticity

Foot slap at LR

or reciprocal inhibition of DF Analysis: Examine strength. Eval muscle activation/ timing of pretibial mm

GOAT:

out of 100. ability to recall events prior to and after the injury. Scores between 100 and 76 are considered normal Determination of PTA 76-100=Normal 66-75=Borderline < 66=Impaired

dysesthesias:

painful sensations do not usually follow a dermatome distribution. Occur where lack of sensation. burning, numbness, pins and needles, tingling. often involve abnormal proprioceptive sensations, causing the individual to perceive a limb in other than its actual position. described as "phantom" pains similar to those experienced by amputees. may be caused by scarring at the distal end of the severed spinal cord.

The splanchnic nerves are

paired nerves that contribute to the innervation of the viscera, carrying fibers of the autonomic nervous system (visceral efferent fibers) as well as sensory fibers from the organs (visceral afferent fibers). All carry sympathetic fibers except for the pelvic splanchnic nerves, which carry parasympathetic fibers.

brunstrom •Stage Five: Movement -

palmar prehension

Neuromuscular deficits with TBI

paresis postural control

Perceptual deficits:

parietal sensory association cortex in the nondominant hemisphere, typically the right

•Step training on a treadmill with BWS could be most effective when

patients with chronic hemiparetic stroke are challenged to walk on the treadmill at speeds closer to normal overground walking velocities.

Glucose: in CVA

pay attention to symptoms and contact nursing if needed

UMN syndrome: Hip/knee (prolonged sitting posture)

pectineus, hamstrings

Exercise and PD

people with PD who start exercising earlier and a minimum of 2.5 hours a week, experience a slowed decline in quality of life compared to those who start later. Establishing early exercise habits is essential to overall disease management.

Stroke in children:

perinatal arterial ischemia, sickle cell, congenital HD, thrombophlebitis, trauma Younger individuals may have a better potential for better recovery

HSP: Mechanical stresses from traction and gravity produce _____

persistent malalignment and pain

Pulmonary Impairment**: •C1-C2, ____nerve innervation and ____respiration are lost • Only accessory muscles are left •Artificial ventilator or phrenic nerve stimulator

phrenic spontaneous

Sling upholstery:

poor pelvic positioning, hips slide forward, thighs fall into adduction and internal rotation

health status WC

poor positioning can affect development of UTI and respiratory infections. Complete bladder emptying is more difficult if a person sits in a posterior pelvic tilt. Does the w/c need to open up for catheterizing. Kyphosis or scoliosis compromises breathing and clearing secretions and increases risk of resp infections Nutritional status: wound healing Impaired swallowing

During the spastic state, abnormal muscle tone may contribute to

poor scapular position (depression, retraction, and downward rotation) and contributes to subluxation and retricted movement. Secondary tightness in ligaments, tendons, and joint capsule can develop quickly. Adhesive capsulitis (intrascapular inflammation: "frozen shoulder") is common.

Sensory Stimulation*** (severe TBI—Rancho II/III): Visual stimulation:

position head for normal visual orientation Eliminate visual distractions attempt visual tracking after fixation ie. Colored light or pen familiar faces or objects photos of family members self in mirror

Spasticity Management: Sustained stretch through

positioning and elongating spastic muscles (brace, cast, standing, etc)

PEEP:

positive end-expiratory pressure. Can be used to increase oxygenation in either AC or SIMV mode. This provides a small amount of pressure during inspiration to help the patient draw in a spontaneous breathe.

AD sy

pounding HA Profuse sweating •Increased spasticity •Blurred vision- cn 3 •Vasoconstriction below level of lesion—pale/dry skin •Constricted pupils

Dorsal column-Medial lemniscal - type

precise localization, high degree spatial orientation-

Altered Motor Programming CVA: Lesions of ________ of either side can produce apraxia

premotor frontal cortex and often seen with aphasia

Multipodus-

prevent contracture, reduce heel breakdown

Swedish Knee cage

prevents genu-recurvatum or knee hyperextension to protect the knee.

Medulloblastomas -

primarily occur in children's cerebellum

Speech -Non-Motor Symptoms: PD

primary impairment (75-90% of pts) - hypokinetic dysarthria Speech: decreased volume, decreased tonal/pitch fluctuations, poor articulation, uncontrolled rate

•Home visits should be made

prior to discharge to determine home's accessibility (CVA) •Home adaptations, assistive devices, and supportive services should be in place before the patient is discharged to home, but that is family's responsibility

Akinesia -

problem in preparatory phase

(TBI) as with Parkinson's. pt's with declarative memory deficits may learn (or relearn) motor skill using

procedural memory. a pt with PTA is unable to describe memories (declarative) or verbalize the steps to complete tasks. However, he may show carryover skills that do not require verbal explanation (procedural). ie, may be able to do sit to stand as you have taught them over and over, can't describe it, but can set into motion the motor program

Poliomyelitis:

the motor neurons are more susceptible of the brainstem and spinal cord.

ALS A palatal lift prosthesis can help with

the nasal quality and can extend speech intelligibility for 6 months. Made by prosthodontist

ALS Examples of first symptoms:

the person may start to notice difficulties with fine motor mvmts (buttoning, pinching, writing) or the person may notice the foot slapping or increased frequency of tripping while walking or with bulbar onset: may notice changes in their voice, difficulty moving their tongue, decreased ability to move the lips, or open or close the mouth (or swallowing).

Mid swing:

the thigh continues to advance as the knee begins to extend; the foot clears the ground

Pre-swing interval

this final phase of stance is the second (terminal) double stance interval in the GC. It begins with IC of the opposite limb and ends with ipsilateral toe off. Weight release and weight transfer are other titles some investigators give to this phase. However, all the motions and muscle actions occurring at this time relate to progression. As the abrupt transfers of body weight rapidly unloads the limb, the trailing extremity contributes to progression with a forward "push" that also prepares the limb for the rapid demands of swing. Hence, the term pre-swing is representative of its functional commitment to initiating the forward motion that is used in swing

Lateral medullary (Wallenburg's) syndrome - vertebrobasilar: In the majority of cases this syndrome is due to

thrombotic occlusion of the ipsilateral vertebral artery intracranially. Some cases are due to occlusion of the posterior inferior cerebellar artery (PICA) itself.

Without O2 supplementation

tissue hypoxia and tissue death may result

cerebral edema is a result of

tissue necrosis and widespread rupture of cell membranes with movement of fluid from the blood into brain tissues.

As Neural Recovery Begins GBS

• AVOID EXCESSIVE EXERCISE • •Energy conservation • •Use of adaptive equipment •After 3 months, in most patients, you no longer have to be afraid of over-fatiguing.

•Hematology •Hgb: < _____ g/dL - transfusing? Monitor vitals for _____ & _____ •Hct: < _____ % - transfusing? Monitor ___ to predict tissue perfusion •WBC: > _____ L - may be due to cancer, infection, trauma/sx < _____ L - may be due to infection, chemo, anemia, autoimmune •Platelets: < _______/L - risk of spontaneous hemorrhage •INR: < ___ - clotting risk > ____ - collaborate with team and proceed with caution and safety net > ____ - hold for risk of spontaneous hemorrhage

•Hgb: < 5-7 g/dL - transfusing? Monitor vitals for tachycardia & orthostatic hypotension •Hct: < 15-20% - transfusing? Monitor SpO2 to predict tissue perfusion •WBC: > 11.0 x 109 L - may be due to cancer, infection, trauma/sx < 4.0 x 109 L - may be due to infection, chemo, anemia, autoimmune •Platelets: < 20 x 10^9/L - risk of spontaneous hemorrhage •INR: < 0.9 - clotting risk > 5.0 - collaborate with team and proceed with caution and safety net > 8.0 - hold for risk of spontaneous hemorrhage

Etiology = Combination: PD: Decreased risk

•High normal uric acid •Anti-inflammatory drugs • •Low Cholesterol •Vitamin D •EXERCISE!!! - early in life

Poliomyelitis- contag

•Highly contagious enterovirus (like cold or flu) via droplets or contact, often from contaminated food/water

Phase 8. Terminal Swing angles

•Hip 20o flexion •Knee 5o •Ankle 0

Primary CNS lymphoma

•Histology is similar to non-Hodgkin lymphoma •Unknown how it arises as the CNS is void of lymphatic tissue •Frequent symptoms include behavioral/personality changes, confusion, dizziness •Poor prognosis (tumor recurs in 90%, < 27% survive 5 years)

PT exam/eval MS

•History - acute vs. chronic symptoms, course • Daily Activity Diary, •Common chronic symptoms: gait, cognition, spasticity, mood changes •Systems Review Tests and measures

MCA Clinical Manifestations:

•Homonymous hemianopsia R/L: temporal blindness L and nasal R so anything L of midline is GONE (can see on R sides) Only appreciate what see- only make R half puzxle, only eat R side of plate L side dn exist anymore Homonymous hemianopsia: optic radiation in internal capsule (only sees 1 side, on both eyes)

UE support devices•Ambulatory patients:

•Humeral cuff: • • •Slings that place elbow in flexion are less desirable

Impaired attention

•Hyperactivity •Impulsiveness •Decreased Attention Span •Easily Distractible -->The distraction can be externally mediated or internally mediated

Rehabilitation PD

•INTENSE EXERCISE IS NEUROPROTECTIVE!! •Reduce functional limitations •Promote participation and independence •Known complications can be reduced or prevented •Quality of life promotion

True PD =

•Idiopathic Parkinsonism •2 distinct clinical subgroups with dominant symptoms including: •Postural instability and gait disturbances (PIGD) •Tremor as the main features •Characterized by slow progression

MS Exacerbations: med mngmt

•If sensory or mild symptoms, allowed to resolve on own, if not... •3-5 day course of corticosteroids •Plasmaphoresis (?) [Plasmaphoresis if traditional steroid treatment doesn't work] •Rehab to restore lost function

Relapses •Can be triggered by (MS)

•Illness - viral or bacterial •Stress •Heat •Poor health [Caused by inflammation. Treated with short course of high-dose corticosteroids (IV or oral)]

Medical Management GBS

•Immunotherapy (both are equally effective) -Plasmapharesis (plasma exchange) [PE] -Intravenous immunoglobulin (IVIg) •Combining these therapies has no benefit •May shorten time to recovery •No effect on mortality Choice between the two is often institution-dependent

Endocrine System acute

•Impaired glucose tolerance •Hyperinsulinemia •Muscles develop insulin resistance •Altered regulation of parathyroid, thyroid, adrenal, pituitary, growth hormones, androgens and plasma renin activity (regulates blood pressure, thirst, and urine output) •Altered circadian rhythm •Altered temperature and sweating response Often appear diabetic while in the hospital- not taking in glucose well so appears in blood stream so appear diabetic

Positioning and other Considerations***

•Impaired joints can affect positioning •Strength and endurance •Sensation/skin integrity** •Vision and Hearing •Health Status

Respiratory Impairments ALS

•Impairments are related to loss of respiratory mm strength and decrease in vital capacity. •Fatigue, dyspnea on exertion, difficulty sleeping in supine, frequent awakening a night, recurrent sighing, excessive daytime sleepiness, morning headaches (due to hypoxia) •Respiratory muscle weakness tends to decrease in a linear manner. •If the pt does not receive ventilatory support, eventual CO2 retention will lead to acidosis, coma, and respiratory failure.

•Support the spine in neutral

•Improve posture •Improve resp function •Decrease tone/spasticity •Decrease pain

•Facilitate Optimal Postural Alignment in all Body Segments, Accommodating for Impairments in Range of Motion •Good alignment:

•Improved balance •Stability •Comfort •Function •Prevents: deformity, asymmetrical posturing, skin breakdown

•Body Weight Support Treadmill Training (acute)

•Improved in functional balance, motor recovery, OG walking, speed and endurance •Improving gait ability and walking velocity •Treadmill velocity and duration increased

Common gait dev CVA: Stance Phase: •Trunk/Pelvis

•Inadequate hip extension •Flexion contracture

Sensory stimulation Guidelines continues

•Include the family and significant others in the program •To improve the quality and quantity of responses as responsiveness increases, direct treatment toward increasing frequency and rate of response, the period of time that patient can maintain alertness, the variety of responses, and the quality of attention to the environment •Try stimulating all the senses

•Critical elements: Support Systems to optimize seating

•Seat to back support angle •Seat to lower leg support angle •Seat depth •Seat width •LE support/placement •UE support/placement •Back support shape

•Highest to Lowest Physical challenge:

•Mini-BESTest: clinical balance test with high sensitivity detecting balance impairments in elderly especially with Parkinson's disease. (not necessarily harder than FGA) •FGA has 10 tasks (all gait) and highest score is without device. (gait, change gait speed, horizontal then vertical head turns, pivot turn, step over obstacle, narrow base of support, ambulating backwards, gait with eyes closed, stairs). High level balance. 10-15 minutes to administer •Berg has 14 tasks: sit to stand, stand 2 min, sit 2 min, stand to sit, transfer, stand EC, stand feed together, forward reach, object from floor, turn head over sho, 360 turn, foot on step, stand tandem, SLS •POMA has 9 balance tasks (16 points) and 7 gait tasks (12 points) for a total of Balance + Gait = 28 points. BALANCE: Sit balance, arise, attempt to rise, stand balance (5 seconds), nudged in standing, EC in standing, 360 turn, stand to sit. GAIT: initiation of gait, step length and step height, step symmetry, step continuity, path, trunk (sway), walking stance.

3.Minimally conscious:

•Minimal evidence of self or env awareness •Cognitively mediated behaviors occur inconsistently and are reproducible or sustained, they can be differentiated from reflexive behaviors •Localize to noxious stimuli •Inconsistently reach for objects •Localize to sound location

CVA stretching wrist...

•Mobilization of carpal bones prior to stretching wrist

Aerobic Exercise Guidelines and Parameters MS

•Moderate intensity (typically) •10-15 minutes/day, 2-4 days/wk •Goal: 30-45 minutes/day, 3-5 days/wk •Monitor response to intensity, especially with changes Rest breaks!!! Teach pacing! -NEVER to fatigue!! -Pause at the very first inkling of fatigue, or before -Must learn to Listen to their BODY

Fatigue - Rehab: How do we treat FATIGUE? MS: •Assessment

•Modified Fatigue Impact Scale •25' walk vs. 10m walk •MMT before and after 6 min walk •Activity diary •Sleep Questionnaire •Depression screening

X: Purposeful Appropriate:

•Modified Independent •Periodic periods of depression may occur •Irritability and low frustration tolerance when sick, fatigued and/or under emotional stress •Social interaction behavior is consistently appropriate

•↑probability of PPS

•More severe acute polio infection •Adolescent or adult at time of acute infection (versus child) •Greater recovery after acute polio •Excessive physical activity - to exhaustion or fatigue

Schwannomas

•Most common is the acoustic neuroma •Can result in deafness/balance impairments by rarely death

Rehab Prognosis MS

•Most do not become severely disabled •2/3 will maintain functional gait (with/without gait aid) •Scooter or walker may be needed for fatigue, energy conservation, balance issues

Proper positioning WC

•Most often, when the seat height is adjusted appropriately, the fingertips should be at same level as the axle when the arms are hanging down to the sides. •Elbows 100-120 degrees:

•Cardiac Function in CVA

•Most strokes are due to vascular disease, many with underlying coronary artery disease (CAD) •Cardiac limitations in exercise tolerance may restrict rehab potential

Document severity of symptoms

•Motion Sensitivity Quotient (MSQ) •Dizziness Handicap Inventory (DHI) •Activities-Specific Balance Confidence Scale (ABC)

Active Rehabilitation 1-3 rancho

•Motor (Re)Learning: Mental and physical fatigue •Restorative vs. compensatory-based interventions [•Bed Mobility •Transfers •Gait-Locomotor training (with and without BWS) •CIMT •Aerobic and endurance conditioning •Resistance Training •Community reintegration]

Compression Neuropathy Prevention acute

•Multipodus boots (PRAFO) •Anti-rotation bar •Positioning with pillows

UMN Clinical Impairments ALS: Impairments related to UMN pathology:

•Muscle weakness •Spasticity •Hyperreflexia •Pathological reflex (Babinski, Clonus, Hoffmann sign) --> Spasticity can eventually lead to contracture and deformities --> Spasticity causes dyssynergic mvmt patterns, abnormal timing, loss of dexterity and fatigue --> As the disease progresses, UMN signs may decrease --> Positive Hoffmann's Sign

•What are the bulbar muscles? (ALS)

•Muscles that control speech, chewing and swallowing (tongue, pharynx and larynx). The term 'bulb' is an archaic term for the medulla oblongata. Modern usage includes pons as well. Muscles of the mouth and throat responsible for speech and swallowing.

•MG is an _____ which causes ______ due to a ______ at the _______. This is caused by antibodies ______ •It is unknown why this occurs but it may be related to the _____ as it is responsible for _______. ________ may elicit reaction or exacerbation. •It is characterized by _____, but ____ and ___ muscles may be involved as well as ____ and _____ muscles. •The following tests are used to diagnose MG: •_____ •______ Test •______ •______ test •Examination should include ______ testing as well as ____ and _____ testing of affected muscles. •PT treatment should include: •____ and ______ •_______ recommendation •________ exercise that _______

•Myasthenia Gravis (MG) is an autoimmune disorder which causes fluctuating muscle weakness due to a reduction in acetylcholine receptors at the neuromuscular junction. This is caused by antibodies attacking or blocking receptor sites. •It is unknown why this occurs but it may be related to the Thymus as it is responsible for immunological self-tolerance. Illness, surgery, stress, medications, menstruation, and bright sunlight may elicit reaction or exacerbation. •It is characterized by eye muscle weakness, but limb and axial muscles may be involved as well as bulbar and respiratory muscles. •The following tests are used to diagnose MG: •Blood tests looking at AChR and Anti-MuSK antibody levels •Tensilon Test •Electrodiagnostics •Ice test •Examination should include oculomotor testing as well as strength and endurance testing of affected muscles. •PT treatment should include: •Fall prevention and energy conservation education •Appropriate AD recommendation •Moderate intensity exercise that does not exacerbate symptoms

Limit Abnormal Movement and Improve Function

•Seating equipment can be designed to inhibit abnormal tone, postures, and movements and to improve health, comfort, and function.

Signs and symptoms MG: •Often, first noticeable symptom is _____ •Occasionally, the first sign is ____ and _____ •Symptoms can range from only _____ to _____ which can include ______ •Symptoms typically______ •Limb weakness greater ____ than _____ •Weakness increases with ____ and lessens with _____ •Typical progression - ____ --> ____ --> ____ --> _____ --> ______

•Often, first noticeable symptom is weakness of eye muscle. •Occasionally, the first sign is swallowing and slurred speech. •Symptoms can range from only eye involvement to other musculature which can include loss of breathing control. •Symptoms typically worsen as the day progresses. •Limb weakness greater proximal than distal. •Weakness increases with activity and lessens with rest. •Typical progression - ocular à facial à bulbar muscles à truncal à limbs

Non-Motor Symptoms: Fatigue** - PD

•One of most common symptoms reported -Increasing weakness and lethargy as the day progresses -Mvmts become arrhythmic with hesitations and arrest --> First few words spoken are loud and strong but taper off quickly as speech continues -Performance decreases with physical effort or mental stress FATIGEU MOST COMMON NONMOTOR

•Common areas attacked: MS

•Optic nerve •Corticospinal tracts •Cerebellar peduncles- info help us coordinate •Posterior columns •Periventricular white matter

Complications/Indirect Impairments MSK CVA

•Osteoporosis (age, immobilized, restricted weight bearing) •Fall Risk:

•Stroke Specific

•PASS-Postural Assessment Scale for Stroke Patients •FIST-Function in Sitting Test** •NIHSS NIHSS 42 points possible (bad) Patients with a score of <4 are highly likely to have good clinical outcomes

Pain- Rehab MS assessment

•Pain scale •Posture and equipment/seating assessment •Central vs. peripheral

Sensory dysfunction Signs and Symptoms - AIDP

•Paresthesias •Pain •May have distal loss of vibration, proprioception, touch and pain

Tracheostomy

•Passy Muir Speaking Valve •Button Neck trauma, upper airway obstruction, inadequate cough or unable to handle secretions If mechanical ventilation required longer than 7 days With activity it is hard to breathe with valve or button on, you may need to remove it so they can tolerate the activity Various oxygen delivery systems can be hooked to tank on wheels Button: last step of wean, close hole. Passy: one way valve, air in when breathe, then closes so air out doesn't escape hole but through vocal chords and out nose/mouth to make sound

PPS•Pt/family Education

•Pathology of polio: initial recovery and PPS theory •Energy Conservation and Pacing •Not "lazy" to use pacing, energy conservation, rest, etc. •Consequences of overexertion •Self management of fatigue and pain •Wellness, prevention, fitness Psychosocial support

Intubated and sedated

•Patient may have a "sedation holiday" •OK to mobilize if responsive to commands, cooperative and oriented- mod Ramsey scale •Make sure circuit tubing not caught on anything. •Transfer towards the ventilator. The circuit tubes usually do not have much slack, making long distance mobilization difficult.

Age consideraton

•Pediatric patients have different normative values than adult patients. •Elderly patients may not tolerate abnormal values as well as young people. patients have

Central line

•Peripherally Inserted Center Catheter (PICC) •Hickman - usually used for chemotherapy •Port-A-Cath

Infections •Potential Neurological Sequelae

•Permanent neurological dysfunction in 20% - 50% of cases •Cranial nerve palsies, sensorineural hearing loss, seizures, cognitive slowness, weakness, spasticity,

Compression Neuropathy- acute

•Peroneal nerve palsy •Compression at fibular head

Meningitis: •___ and _____ become inflamed, a ______ forms. Resulting in obstruction of ______, the _______, or the exit _______. •The mechanism for headaches may be _______ and the stretching of the meninges and pain fibers associated with blood vessels. •Vomiting may be a result of stimulation of the ________ center.

•Pia and arachnoid become inflamed, a purulent exudate forms. Resulting in obstruction of foramen of Monro, the aqueduct of Sylvius, or the exit foramen of the 4th ventricle. •The mechanism for headaches may be increased intracranial pressure and the stretching of the meninges and pain fibers associated with blood vessels. •Vomiting may be a result of stimulation of the medullary emetic center.

Chest tubes

•Placed into chest cavity to remove excess fluid or air. •Used in open heart surgery, thoracic trauma, injury, disease, etc. •Usually inserted into LEFT 4th-5th rib space. •For ↓ drainage, Jackson-Pratt (JP) drainage bulbs may be used.

Continuum of support surfaces

•Planar surfaces •Deformable surfaces •Contoured surfaces • •Custom-molded surfaces

•Serial Casting locations TBI

•Plantar flexors or bicep contractures •Until satisfactory gains or no further progress is made •Risk of skin breakdown Sometime wrap in pillow, just to protect the sound limb

Indications for removal (emergent)

•Poor circulation in the casted extremity: weak pulse, nail bed does not quickly return to its original color after being squeezed gently, cold to the touch, swelling. •Evidence of or severe complaints of pain possibly indicating muscle spasms or skin breakdown, point tenderness •Skin reaction such as rash, blisters, or abrasions •Unusual odor from cast

•Sit <>stand CVA

•Position feet back to allow ankle DF to assist with forward rotation •Place hands on swiss ball or armed chair placed in front of patient to work on getting trunk forward and focus on extensor phase of hips and knees

Phase 5. Pre-Swing: Objectives

•Position the limb for swing (thigh/knee flex) •Accelerate progression

Center/Mid-Wheel drive: p

•Positives: •Now the most commonly used base • •Most stable on slopes

CVA: Lack of ability for adjustment of postural muscles in preparation for and during a movement task are impaired, leading to:

•Postural abnormalities •Balance impairments •Increased fall risk

Nutritional Management: •Protein can block the ------- •Advised to eat a -----, ---- diet (___% of calories from protein) •Shift intake of protein to ____ meal when pt is less active •Increase ---- intake and ----- to alleviate ----- •Try to get -- AND ---- from food instead of supplements, especially vitamin --- •Supplement ---- INSTEAD of through diet due to ---- causing greater difficulty with ------

•Protein can block the absorption of L-dopa •Advised to eat a high-calorie, low-protein diet (15% of calories from protein) •Shift intake of protein to evening meal when pt is less active •Increase water intake and dietary fiber to alleviate constipation •Try to get antioxidants and vitamins from food instead of supplements, especially vitamin E •Supplement Calcium INSTEAD of through diet due to dairy protein causing greater difficulty with levodopa absorption

Spasticity/Stiffness- Rehab MS: •Assessment

•ROM •Modified Ashworth •Medication management

osteoporosis in sci timeline

•Rapid in the first 4 to 6 months • continues to decrease up to 3 years after injury

GBS Cardinal clinical features

•Rapidly evolving •Relatively ASCENDING muscle weakness/flaccid paralysis

PD •Postural instability - What does it look like?

•Rare in early stages (<5 years) •Anticipatory •Reactive [abnormal and inflexible postural responses; increased body sway; coactivation; feed-forward strategies for self-initiated movements] NOT early

Lymphatic System acute

•Reactivation of latent viruses •Decreased production of interleukin-2 cells (responsible for growth, proliferation, and activation of T and B lymphocytes) •Increased levels of Interleukin-1(β) cells (promote bone mineral loss) •Decreased level of circulating plasma Antibodies

Posterior Cerebral Artery Syndrome***Clinical Manifestations

•Recent memory loss may be present (hippocampus) and/or a confusional state initially

How many people live with MS?

•Recently found that TWICE as many people as previously thought

Chronic SCI ***Fitness: Injury within or below thoracolumbar sympathetic output

•Reduced exercise tolerance •Lower stroke volume •Reduced cardiac output Deconditioning due to physical inactivity and impaired cardiovascular system A regular cardiovascular fitness exercise program is an important component of rehab

Aseptic Meningitis (viral)

•Refers to nonpurulent inflammatory process confined to the meninges and choroid plexus, usually viral. •Symptoms similar to bacterial but less severe •May be irritable, lethargic, headache but cognitive function remains intact. •Benign and relatively short course of illness •Primary nonviral causes -->Lyme Borrelia -->Leptospira •Dx: --> Infecting agent within the CSF --> Glucose level in viral meningitis is normal (remember with bacterial it is depressed) •Full recovery is expected in a few days to weeks.

Indications for removal (non-emergent)

•Refusal to bear weight on casted extremity •Changes for the worse in sleeping/mood •Dampness •Slipping in cast (pistoning) [heel rubbing, now break down] •Redness/chaffing without significant swelling or skin breakdown •Increased complaints of itching •Knowledge of objects dropped into cast

Improving LE function

•Regardless of the initial level of locomotor function, patients spent most of their time in PT doing gait •Emphasis of gait occurs at the very beginning of rehab (first day)

The chair is designed for

•Require the w/c for long term use (greater than 2 hr/day and 3 months duration) •Those who cannot self propel a standard manual wheelchair but can propel the high strength light-weight manual wheelchair •Designed to further customize to the individuals needs •All consumers who receive a manual wheelchair should also receive a seat cushion for the manual wheelchair

Ultra-Lightweight Manual Wheelchair: The chair is designed for

•Requires a long term, full time, lifetime use of the wheelchair •Designed to be changed to a very customized configuration to meet the high-end need of the very active client •Designed to be very light weight, to qualify the wheelchair must be under 30 lbs •Designed for the end user who is tough on their equipment due to their activity level •The rear axle must be adjustable up and down, forward and back •For consumers who weight ≤ 250 lbs.

respiratory : note (sci)

•Respiratory exam and function, chest expansion, breathing pattern/rate, cough, vital capacity, etc

Therapeutic skills CVA

•Retrieving objects from floor •Carrying objects while walking

Encephalitis- 5 Pathological Syndromes: Acute toxic encephalopathy

•Reye's syndrome

Trunk/assessment/positioning: Assess all levels/curves of spine:

•Rib cage •Scapula •Head

Contributors to Postural Instability PD

•Rigidity •Decreased muscle torque •Weakness •ROM and trunk flexibility torque production is decreased at all speeds - especially extensors motor unit recruitment is delayed once initiated, asynchronization (pauses and inability to smoothly increase firing rate as contraction continues) Disuse weakness

•Intracerebral Hemorrhage (ICH)

•Rupture of a cerebral vessel with bleeding into the brain parenchyma •Primary Cerebral Hemorrhage (nontraumatic spontaneous hemorrhage) •typically occurs in small blood vessels weakened by atherosclerosis producing an aneurysm.

Benefits of Optimal Sitting Posture

•Safe swallow •Optimal breathing •Digesting food • •Reduce risk of developing deformities (spine or joint contracture) •Improve motor control of head, trunk, arms, hands communicate, project voice, eye gaze

•Primary muscles of Inspiration:

•Scalenes and intercostals (stabilize/elevate ribs) •Accessory: SCM, pec major/minor, serratus, trap, levator abdominals

Power wheelchair base***

•Scooters •Rear Wheel Drive Bases* •Center Wheel Drive Bases* •Front Wheel Drive bases*

Postural Support System: •Components that directly affect comfort and posture are:

•Seat surface •Back surface •Pelvic positioning •UE surface •LE surface