Common Neurologic conditions

Basics of DDx- UMN disorders

• Conditions: Strokes, SCI, TBI, CP, MS, ALS

• Structures involved- cortex, brain stem, spinal cord

• Tone- increased spasticity, velocity dependent

• Reflexes- Hyperreflexia and abnormal reflexes → clonus, babinski

• Sensation- decreased

• Involuntary mvmts- muscle spasms

• Voluntary mvmts- mvmt in synergistic patterns

Basics of DDx- LMN disorders

• Conditions: GBS, Peripheral nerve injury, Polio, ALS

• Structures: peripheral nerves, nerve roots, cranial nerves

• Tone: decreased → hypotonia

• Reflex: hyporeflexia

• Sensation: decreased

• Involuntary mvmts: denervation → fasciculations

• Voluntary mvmts: weak or absent

Basics of DDx-Basal Ganglia

• Conditions: Parkinsons, Huntington’s

• Structures involved: Basal Ganglia

• Tone: Increased rigidity, not velocity dependent

• Reflexes: Decreased or normal

• Sensation: normal

• Involuntary mvmt: Resting tremors

• Voluntary mvmts: Bradykinesia, akinesia

Basics of DDx- Cerebellum

• Conditions: cerebellar strokes, tumor

  • ipsilateral s/s

• Structures involved: cerebellum

• Tone: decreased or normal

• Reflexes: decreased or normal

• Sensation: normal

• Involuntary mvmts: nystagmus

• Voluntary mvmts: Ataxia, intention tremor, dysdiadochokinesia, dysmetria (balance & coordination)

Parkinson’s disease

• Progressive neurological disorder caused by the depletion of dopamine in the substantia nigra

• older adults

• Males > females

PD s/s → Cardinal signs

• Tremor (resting)- pill rolling, usually U/L

• Rigidity- Cogwheel or lead pipe, initially asymmetrical and proximal

  • lead-pipe → smooth and consistent

  • cogwheel → ratchet-like

• Akinesia- cannot initiate mvmt or “freezing”, bradykinesia v. hypokinesia v. akinesia

• Postural instability- thoracic kyphosis and forward head

Other s/s of PD

• Early s/s

  • Loss of smell

  • Constipation

  • Sleep disorders

• Motor: hypophonia, mask-like face, micrographia

• Cardio: Orthostatic hypotension, fatigue, weakness

• Respiratory: restrictive lung disease due to decreased chest expansion

• Cognition/ behavior: difficulty w/ dual tasking, depression, dementia

PD Gait

• Freezing of gait: sudden inability to initiate mvmt

  • Tx: visual targets, music, wide doorways/ modify environment

• Festinating gait: short stride, shuffling, increasing speed, anteropulsion

  • Tx: add toe wedge or declined heel to move COM posteriorly

• Decreased step width and step length

• Decreased trunk rotation and arm swing

• En bloc turning (Turn like a robot)

PD interventions

• Caregiver education

• Gait training- metronomes, music, visual cues, one-step commands when freezing/ frozen

• Posture- rotation exercises and crossing midline, prone lying

• Hypokinesia- BIG movements, stretching, ROM, chest mobility

• Balance training

• Tai Chi, yoga, cycling, dance therapy

Dyskinesia v Dystonia

• Dyskinesia- involuntary, repetitive, smooth, muscle mvmts

  • affects large muscle groups (arms, head, trunk, legs)

  • Not usually painful

  • ON phase

• Dystonia- Prolonged, involuntary muscle contractions; muscle spasm

  • Affects a specific muscle or groups of muscles

  • Causes pain (sometimes debilitating)

  • OFF phase

PD- Pharmacological Tx of PD

• Levodopa/ Carbidopa → combo (need both to cross BBB)

  • Gold standard

  • Higher level levodopa delivered to brain

• On/ Off phenomenon: random fluctuations in motor performance and responses

  • Dyskinesia: on phase

  • Dystonia: off phase

    • Schedule PT one hour after dose of levodopa

      • High protein diet can block effectiveness

Hoehn and Yahr classification of disability

• 1- Minimal or absent disability, unilateral if present

• 2- minimal bilateral or midline involvement, balance not impaired

• 3- Impaired righting reflexes, unsteadiness when turning or rising from a chair. Some activities are restricted, but patient can live independently and continue some forms of employment

• 4- All s/s present and severe. Standing and walking possible only with assistance (Assistive device)

• 5- Confined to bed or wheelchair (dependent)

Multiple Sclerosis

• Autoimmune disease affecting UMN/ CNS

• Progressive demyelination of the neurons in CNS

  • decreases conduction velocity in CNS

S/S of MS

• Motor: spasticity

• Sensory: numbness and paresthesia

• Gait: scissoring, extensor spasticity in LE, ataxia, uneven steps

• Bladder: spastic, flaccid

• Speech and swallowing: dysphagia (difficulty swallowing), dysphonia (difficulty w/ voice production)

• Cognition: diminished attention, concentration

• Fatigue

• Optic neuritis, trigeminal neuralgia

• Cerebellum: nystagmus, coordination, balance, ataxia, intention tremor

• Emotion: pseudobulbar affect (inappropriate laughing or crying)

Unique s/s of MS

• Lhermitte’s sign- neck flexion → shock sensation down spine

• Uhthoff’s Phenomenon → exacerbates s/s in heat >85 degrees for around 24 hrs

• Charcot’s Triad → scanning speech, intention tremor, nystagmus

  • When cerebellum is affected by MS

• Cranial nerve 2 → Optic nerve neuritis

  • pupil constricts paradoxically (dilates when it should constrict) → Marcus Gunn Pupil

MS Types

• Relapsing- remitting: short-duration attacks with full or partial recovery, may or may not leave lasting s/s, most common (about 80%)

  • will most likely convert to secondary progressive

• Primary Progressive: steady increase in disability without attacks/ exacerbations

• Secondary progressive: Initially RR, then s/s increase without periods of remission

• Progressive relapsing: steady increase in disability w/ superimposed attacks (worst type)

  • Eliminated from usage in 2013

• Clinically isolated syndrome (CIS)- first episode of inflammatory demyelination in the CNS → could become MS if additional activity occurs

  • not active- no additional MRI activity

  • Active- with additional MRI activity

MS interventions

• Do not over-fatigue

• Manage overheating/ temperature

• energy conservation

  • 3-5x a week on alternating days

  • low intensity (3-5 METS)

  • 30 min sessions

  • cycle, walk, swim, circuit training

• Exercise is best in the morning

• include coordination and balance training

Amyotrophic Lateral Sclerosis (ALS)

• Progressive neurological disorder that damages nerve cells and causes disability

  • UMN + LMN s/s with sensory sparing

S/S ALS

• UMN & LMN presentations without sensory loss

  • Muscle atrophy, fasciculations (LMN)

  • Spasticity, hyperreflexia (UMN)

  • Dysphagia, dysarthria (bulbar)

• ONLY motor neurons will be affected

• Cognition: dementia, attention deficits

• Emotion: pseudobulbar affect

• Muscles: Cervical spine extensor weakness is common (pt. falls into neck flexion)

• Respiratory muscle weakness → death

ALS intervention

• Medical management- no effective Tx for disease

• PT management

  • focus on functional activities/ ADLs and energy conservation initially and end stages

  • Recommend soft foam collar for neck if weakness is present

  • Maintain respiratory Fxn, breathing exercises

  • Avoid over-fatiguing

    • take frequent breaks during activities, energy conservation techniques

  • ROM, positioning if needed

Guillain- Barre syndrome (GBS)

• Autoimmune s/p infection

• Acute inflammatory demyelinating polyradiculoneuropathy

• Rapid loss of myelin in nerve roots, peripheral nerves and cranial nerves

• LMN disorder

S/S of GBS

• Motor loss/ paralysis

  • Distal → proximal (ascending paralysis)

  • Rapid and progressive

• Sensory loss

  • Glove and stocking- normally bilateral and symmetrical

  • Burning, tingling, numbness

• Decreased reflexes/ areflexia

• Respiratory and cranial involvement

  • 7,9,10,11,12

• Fatigue

GBS intervention

• Respiratory care

• Teach energy conservation techniques

• Avoid overuse and fatigue (can prolong recovery)

• Recovery: 6-12 months, may recover fully

  • LMN injury- better prognosis