Hyper-excitability PT Implications

focal seizures, partial seizures

seizures that occur in very specific parts of the brain

generalized

seizures that eventually activate networks in both hemispheres of the brain

status epilepticus

a prolonged seizure or situation when a person suffers two or more convulsive seizures without regaining full consciousness; MEDICAL EMERGENCY

aware focal, simple partial

seizures that do not affect consciousness, but create abnormal movements or perceptions based on their locations

impaired awareness, complex partial

seizures that affect consciousness for >30 seconds, and are typically localized to the medial temporal lobes

generalized motor, tonic-clonic

Most common type of generalized seizures

tonic phase

phase of generalized motor seizures characterized by the loss of consciousness and contraction of all muscles for 10-15 seconds (causing extension of limbs, falling, and expiratory moan)

clonic phase

phase of generalized motor seizures characterized by rhythmic bilateral jerking contractions that gradually slow and stop over a period of 0.5-2 minutes

non-motor generalized/absence seizures

brief episodes of staring, unresponsiveness, and amnesia lasting for up to 10 seconds

sensory changes, dizziness, hallucinations, increased/decreased movements, difficulty breathing, incontinence

clinical symptoms of seizures

duration, rate of recovery

How do we distinguish complex partial and absence seizures?

electroencephalography

diagnoses of epilepsy

psychogenic nonepileptic seizures

If EEG is never abnormal in a patient with seizures, what is there diagnosis?

CT/MRI

Diagnostic methods useful to rule in. ot out a tumor or vascular disease

1. Prodromal

2. Early ictal (aura)

3. ictal

4. post ictal

phases of a seizure

febrile seizure

convulsions brought on by a fever in infants or small children.

drugs, surgery

Two main groups of treatment for seizures

decrease neuronal activity

main function of medications/anticonvulsants to tx epilepsy

False

True or false? There is typically no hesitancy to put young kids and teens on seizure medications.

ataxia, nystagmus, dysarthria, fatigue

Common side effects of epilepsy medications

70

epilepsy medications are effective for what % of people?

focal resection, callosotomy, hemispherectomy, deep brain stimulation

Tx options for epilepsy when medications do not work

focal resection

Patients with focal, unilateral seizures in non-vital brain regions (e.g., associational areas of the cortex) are good candidates for what type of surgery to tx seizures?

Severs corpus callosum, ↓ spread of seizure activity in the brain

How does a callosotomy tx seizures?

< age 3

hemispherectomies are only performed in what age grou?

deep brain stimulation

electrical stimulation applied through surgically implanted electrodes, giving constant electrical stimulation to override the abnormal electrical activity

early treatment

what is the key to an improved prognosis for epilepsy patients?

75%

If your patient with epilepsy has no known cause and they have a diagnosis AFTER 2 years old but BEFORE 10 years old, what is their remission rate?

5 years seizure free

what constitutes remission from epilepsy?

75

If a child hasn't had a seizure for 4 years and they are on medication, what % chance do they have that they won't have another seizure in their lifetime when drugs are withdrawn?

10%

If someone has uncontrolled epilepsy for 4 years, how likely are they to find a successful treatment?

60%

If someone has uncontrolled epilepsy for 1 year, how likely are they to find a successful treatment?

unlikely

With the exception of febrile seizures, epilepsy onset before the age of 2 indicates a likely or unlikely chance of remission?

depression and suicide rates, asphyxiation, prolonged seizure

3 reasons for higher mortality rates in those with epilepsy

until recovered from post ictal phase

how long should you stay with a person having a seizure?

time it, check medical ID, move from harm, turn to sidelying, loosen tight clothes around neck

what actions should you take when you notice someone having a seizure?

restrain, put something in their mouth

What should you NOT do when someone is having a seixure?

1. 5 minutes

2. does not return to normal

3. injured, pregnant, sick

4. repeated seizure

5. 1st seizure

6. Difficulty breathing

7. Seizure in water

7 criteria for calling 911 when someone is having a seizure

eliminate/prevent triggers, screen activity, supervision, safe environment

Steps to ensure safety in the PT clinic for patients with epilespy/seizures

True

True or false? Seizures often occur after activity

2-3 months

How long are activity levels limited after the first seizure?

2-3 month limited activity

If an individual is taken off their seizure medications in later life, what is their impact on mobility

episodic

classification of tension headaches that occur

chronic

classification of tension headaches that occur 12-180 days/year

increased cervical/shoulder tension, tightness, dull pain, tenderness, photophobia, phonophobia, nausea

Clinical Symptoms of tension headaches

International Classification of Headache Disorders

Diagnostic tool for tension headaches

≥ 10 episodes occurring in

According to the International Classification of Headache Disorders, what is the occurrence of tension headaches require for a diagnosis?

30 minutes-7 days

how long do tension headaches last, according to the International Classification of Headache Disorders

At least two of:

• bilateral location

• pressing, tightening quality

• mild/moderate intensity

• not aggravated by routine physical activity

Both of:

• NO nausea or vomiting

• NO more than one of photophobia or phonophobia

What characteristics are required by the International Classification of Headache Disorders in order to diagnose tension headaches?

improves posture, prevents abnormal neck muscle contractions

How can PT improve tension headaches?

Analgesics/NSAIDs, tricyclics (chronic), lifestyle changes

Treatments for tension headaches, other than PT

pervasive negative thoughts

What increased the risk of episodic tension headaches developing into chronic tension headaches?

1. female gender

2. no medication overuse

the 60% chance of tension headache remission is more common in those with what two traits?

postural/relaxation exercise, biofeedback, manual therapy, cervical motor control training, ergonomics, dry needling

PT specific treatments that are useful for TTHs

SCREEN FOR OTHER SYSTEMS

Safety considerations when dealing with patients with TTHs

Cervicogenic headaches

Headaches originating from the neck.

increasing pain, up to 72 hours, throbbing, scalp tenderness, unilateral, sensitivity to light/sound/movements, nausea/vomiting, allodynia

Clinical Symptoms of migraine headaches

allodynia

Pain due to a stimulus that does not normally provoke pain

aura

typical warning sign that occurs before a migraine

scintillating scotoma

visual light disturbances with light that precede a migraine

scintillating scotoma, paresthesia of hand/face, vertigo/dizziness

What three things can often be part of an aura?

complicated migraine

migraine with transient sensory or motor impairments.

5 attacks (that fulfil the rest of the criteria)

Diagnosis for migraine without aura involves what "occurrence" criteria?

lasting 4-72 hours untreated (or unsuccessfully treated)

Diagnosis for migraine without aura involves what "time" criteria?

two of the following:

1. unilateral location

2. pulsating quality

3. moderate/severe pain

4. aggravation by physical routine

one of the following

1. nausea, vomiting

2. photophobia AND phonophobia

Diagnosis for migraine without aura involves what "characteristic" criteria?

2 attacks (following remaining criteria)

Diagnosis for migraine with aura involves what "occurrence" criteria?

one or more of the reversible aura symptoms:

1. visual

2. sensory

3. speech

4. motor

5. brainstem

6. retinal

at least two of the following:

1. 1 aura symptoms spreads over 5 min, or two or more symptoms occur in succession

2. each aura symptom lasts 5-60 min

3. one aura symptom unilateral

4. aura accompanied or followed w/in 60 minutes by a headache

Diagnosis for migraine with aura involves what "characteristic" criteria?

dark/quiet room, aerobic exercises (if not a trigger), meds, trigger prevention, botox (chronic)

Treatments for migraines

fewer headaches, absence of allodynia

Migraine remission is more likely with what characteristics?

stroke

What medical emergency are individuals with migraines (with aura) more prone to?

↑ fall risk, imbalance

Safety considerations for those with chronic, aura migraines

sudden and unilateral extreme pain, behind eye/frontotemporal region, autonomic changes (bilateral)

clinical symptoms of cluster headaches

sweating, tearing, nasal congestion, constricted pupil, droopy eyelid

what kind of autonomic changes may be seen with cluster headaches?

horner's syndrome

collection of signs relating to injury of the cervical sympathetic innervation to the eye: ptosis, anhidrosis, miosis

episodic cluster headaches

clusters of daily headaches for weeks followed by months of none

<14 day remission period with cluster headaches occuring for at least 12 months

What defines a chronic cluster headache?

alcohol, sleep pattern changes

what things can worsen cluster headaches?

at least 5 attacks

Cluster headache diagnosis criteria for "occurrence"

unilateral orbital, supraorbital and/or temporal pain 15-180 minutes (untreated), frequency around 1 every other day and 8 per day

Cluster headache diagnosis criteria for "time"

Either or both of the following:

1. one of the following, ipsilateral to headache

• eyelid edema

• congestion or rhinorrhea

• conjunctival injection/lacrimation

• forehead/face sweat

• miosis and/or ptosis

2. restlessness or agitation

Cluster headache diagnosis criteria for "characteristics"

medications, modifying risk factors, deep brain stimulation

Treatments for cluster headaches

nasal sprays

what form of meds are typically given for cluster headaches?

20%

what % of people have lost a job secondary to cluster headaches

8

what % of people are out of work or are on disability due to cluster headaches

55

what % of people with cluster headaches have suicidal ideations?

False (same chances for complete remission, milder attacks, or similar attacks for life)

True or False? for those with cluster headaches, it is more likely they will have similar attacks throughout their lifetime.

education on lifestyle factors (sleep, alcohol, anxiety), upright posture

What treatments considerations can we use at PTs for cluster headaches

tension

What type of headaches can be treated very well with PT?

cluster, migraine

What type of headaches are not able to be treated with PT alone, and often need further medical management?

Headache journaling

If an individual has frequent headaches, what would be an appropriate task to recommend?