Neurodegenerative Conditions 😶‍🌫️

ALS, MS, Huntington’s, Guillain Barre, Parkinson’s, Dementia

Akinesia

-freezing gait/ other movements

-teaching rocking is useful in helping clients initiate movement

Ataxia

-uncoordinated movements, tremors may be present

~you need to call “a taxi” because you’re uncoordinated

-tx: stabilize proximally to help distal movements; pt can use unaffected side over hand with tremor to help with fine motor tasks; orthoses like c-collar/wrist splints can help to reduce impact of tremors

Dysmetria

decreased coordination of movements *dysmetria ~ off meter/ off beat

Festinating gait

Shuffling gait- small, quick steps from forward-tilted head and trunk posture

Special Evaluation Consideration for Neurodegenerative Conditions

-How pt’s disease may progress and/or have variable symptoms (e.g. symptoms that change during the day/week/month/seasons)

-Pt’s understanding/ level of acceptance of progressive nature of disease

General Neurodegenerative Disease OT Interventions

-Help client compensate/adapt as function declines

-Ex: cognitive compensatory strategies, energy conservation, environmental mods, adaptive equipment, exercise, caregiver training

Multiple Sclerosis

-slowly progressing CNS disease of demylenation
-Acute/beginning is weakness, paresthesia, visual disturbances, emotional disturbances
-Long term is typically fatigue, general weakness, intention tremors
-Balance issues, bowel/bladder, spasticity

4 types: relapse remitting (best), secondary progressive (has some neurological dysfunction), primary progressive (no remission, neuro function worsens), progressive relapses (worse)

MS intervention

-Gentle ROM is good, so is caregiver education
-Strengthening is usually a bad thing
-cognitive and physical abilities can vary throughout the day- try to time sessions when pt usually feels the most energized

-can benefit mentally/emotionally from group-therapy/CBT

-sitting with at least 90 hip flexion can help reduce spasticity

Amyotrophic Lateral Sclerosis (ALS)

-Motor neurons in CNS & PNS are replaced by scar tissue over time (plaques)

-AKA Lou Gehrig’s disease

-disease progresses distally to proximally (most common first symptoms are weakness in small hand muscles or asymmetrical foot drop)

-Stage I-III can walk but growing weakness

-Stage IV- requires w/c, some assistance with ADLs

-Stage V- W/C, Dependent with ADLs

-Stage VI- unable to get out of bed

-Cognition, sensation, vision, hearing, bowel/bladder usually NOT affected

Interventions:

-because it is progressive/degenerates a large part of functional skills, CAREGIVER education is really important for issues
early stage: try to keep some muscle, just dont overexert
middle stage: muscle loss will happen, better for ROM
late stage: ulcer prevention

-W/c recs: often start with high backed, reclining, light weight, small turning radius, with head/trunk/extremity support then progress to power W/C with adaptable controls

-Use voice operated/hands-free teach

-Can extend ability to drive a car by using hand controls and adding W/C lift

CP - Diplegia

-More involvement of the LE
-Less impairment to UE

Presybyopia

Decreased ability to focus clearly on close objects, and switching from near to far

General Parkinson’s Info

-resting tremors of hand (not usually present during sleep/voluntary mvmnts)

-muscle rigidity (high tone, cogwheel motions, fatigue)

-bradykinesia

-postural instability (stooped posture, lack of arm swing, inc fall risk)

-stress exacerbates symptoms

-life expectancy usually not impacted but QOL is

-eval- COPM to find “empowering” goals, evaluate at multiple times of day to get accurate picture, may need to screen cognition/depression

-int: freezing (avoid crowds/tight spaces/turns/rushing/clutter/distractions); instruct on use of cane/walker; counting/singing/auditory cueing can help make movements smoother

Feeding (built-up/weighted utensils/spill guards, increased time to eat, distal wrist weights for tremors, put arms on table and keep items close to body to inc stability)

Movement (LSVT BIG for gross and fine motor coordination- need cert)

Early stage parkinsons

-Decreased interest in social/leisure activities

-Starts with Stage I- unilateral symptoms, function maintained

Middle stage parkinson

-problems with self-feeding, IADLs

Late Stage Parkinsons

-alongside tremors, rigidity, balance
-oral motor deficits start to happen

-Ends with Stage V- total dependence for ADLs

Parkinsons and medications

-try to time therapy with med delivery as it can help with performance in therapy

-meds usually impact dopamine levels

Extrapyramidal Syndrome

-movement disorders such as akathisia (cant stay still), dystonia (twisting motion), and parkinsonism (tremors) caused by antipsychotic drug therapy
-dangerous if working with tools

Huntington’s Disease

-characterized by uncontrollable body movements and degeneration of the nervous system; usually fatal ~20 years after the onset of symptoms.

-fatigue (activity mod/breaks), incoordination and dec motor control (AE)
-difficulty with some cognition (word retrieval), problem solving skills

-early stages- difficulty maintaining work performance

-middle stages- difficulty with memory and decision making

-later stages- dysarthria makes speaking difficult

Evaluation: Unified Huntington’s Disease Rating Scale- assesses motor, cognitive, functional, and behavioral changes

-Intervention: should be compensatory

Early on mods should focus on activities that require fine motor skills (fastening zippers, buttons, hooks, etc.) since challenges are usually limited to fine motor coordination at the beginning

Acute Guillain-Barre Syndrome

-onset is sudden and rapidly progressing- usually starts with paralysis of feet that moves up

-most prominent factors is decreased strength of muscles which can lead to swallowing issues, fatigue (biggest pt complaint), and pain

Plateau Guillain-Barre Syndrome

-where symptoms are worse, may need ventilator
-paralysis of the muscles of the head and neck can affect speaking, swallowing

-OT eval often covers positioning to prevent skin breakdown, communication, control of phys env, comfort, and anxiety management

-Intervention:

-train communication tools (signs/picture boards),

-adjust laying/sitting positions to optimize function/comfort and limit risk of skin breakdown (teach caregivers as well)

-Position client for trunk/head/ UE stability

-Educate pt/family about condition and anxiety-reduction techniques

Recovery Guillain-Barre Syndrome

-GBS has no cure but ~80% of pts can walk after 6 months, 60% get full strength back after a year

-OT eval focuses mobility, ADLs, communication, and community/work reintegration

Intervention:

-energy conservation/fatigue management good diet
-gradually increase tolerance of complexity of task

-dynamic splints can help maintain ROM for wrist/fingers/ankle i.e. hinged drop-foot orthosis

-Adapt modes of communication based on client (e.g. speech to text on phone)

Dementia vs. Normal Aging

-If a change is noticed look deeper

-Treatable causes of change- mental health issue, physical health issue, medication complication, sensory change like hearing loss, new chronic condition like diabetes

Dementia vs. Alzheimer’s

Dementia- not a diagnosis, but a general umbrella term for deterioration of brain capacity (at least 2 parts of brain are dying)/cognitive decline that is constantly changing; consists of 85-90 different conditions; can’t be fixed/stopped at least right now

Alzheimer’s- most common form of dementia (~75%), associated with specific patterns of brain changes

Vascular Dementia

-from series of mini strokes

-Cognitive deficits similar to Alzheimer’s but with better memory in tact

-Gait impairment

-Typically see sudden appearance/ abrupt worsening of symptoms

-Requires immediate emergency medical attention

Frontotemporal Dementia

-marked by behavioral changes such as impulsive, listless, inappropriate social, lack of empathy, loss of insight to behaviors, increased sex drive, progressive aphasia, symptoms similar to Parkinson’s

-Sudden onset

-Medical tx still in development

Dementia with Lewy Bodies

-Marked by visual hallucinations and parkinson’s-like motor symptoms

-gradual progression

Early Stage Dementia

-Increased irritability
-difficulty with wayfinding affecting community mob

Middle Stage Dementia

-Don't leave them alone, they may get lost
-Moderate IADL issues
-Pacing issues, difficulty making choices (like with clothes), general confusion/difficulty recalling recent events
-Issues with judgement of direction, distance may increase falls
-May have visual/perceptual issues, difficulty with reading
-They may think they’re in an earlier stage of life

Late Stage Dementia

-Difficulties with posture and balance
-Swallowing and chewing difficulties
-Speaking issues, likely not able to speak enough to say weird/delusional things

Dementia knowledge

-Observation and interviewing family is good for assessment
-Most assessments likely too cognitively challenging
-Family can use locks, door/bed alarms, visual barriers for safety
-Visual cues are good for memory issues, as well as bathroom schedules for independence

Stage I Alzheimer’s

Cognitive Decline:

-Very mild to mild cognitive decline

Key Characteristics/Concepts:

-Mild memory problems (family and friends may not notice yet)

-Perceived loss of control/ competence that used to be there

-Can cause anxiety/fearfulness

-Socially and physically intact

Quote to Remember:

-“Is there a problem?”

ADLs/IADLs:

-ADLs & IADLs intact

Task Performance:

-Can teach new tasks but grade activities for success to promote participation/decrease anxiety

-Use auditory/visual/kinesthetic input

-Environmental aids are helpful- central location for putting things, sticky notes, notebooks, calendars, etc.

Stage II Alzheimer’s

Cognitive Decline:

-Mild to moderate cognitive decline

Key Characteristics/Concepts:

-Moderate memory loss

-Denial, moodiness, paranoia

-Difficulty learning new tasks

-Lose valued objects

Quote to Remember:

-“I just want to be left alone”

ADLs/IADLs:

-ADLs intact

-IADLs moderately compromised/challenging (think managing finances, cooking, shopping, etc.)- this can contribute to isolation

Task Performance:

-OT provides environmental supports and cues to help remember important things/events

-Help maintain and provide structure/routine

-Use reorientation items like pictures to help remember identity/past/protect important relationships

-Exercise like stretching/walking/balancing

-Consider resources like day-care/ volunteers to do home checks

-Provide very simple and clear instructions with NO new tasks

Stage III Alzheimer’s

Cognitive Decline:

-Moderate to moderately severe cognitive decline

Key Characteristics/Concepts:

-Agitated, apathetic, violent esp. when overwhelmed

-Not oriented to time/place

-Unaware

-Sleep disturbance

-Wandering behaviors

-Impaired visual and spatial orientation (think of jumbled clock drawing)

Quote to Remember:

-“Go away! Who are you?”

ADLs/IADLs:

-ADLs/IADLs are compromised

-May see urinary incontinence

Task Performance:

-Prioritize safety (remove dangerous objects like knives, consider safety ID bracelet/cameras)

-Lighting/pictorial cues for “over learned” tasks with less than 2-3 steps

-Rehearse names/pictures of family

-Help caregiver with responding to/managing behaviors

Stage IV Alzheimer’s

Cognitive Decline:

-Severe cognitive decline

-Also see severe physical decline at this stage

Key Characteristics/Concepts:

-Generalized motor slowing —> bed-ridden

-Incontinent

-Unable to communicate clearly beyond one word

-Nursing home likely necessary

Quote to Remember:

-“No, jakfnsdj;?”

ADLs/IADLs:

-Severely impaired

Task Performance:

-Prioritize bed positioning and comfort of pt

-Use sound, touch, and vision to help maintain contact with reality

-Instruct caregiver on skin integrity and transfers

Screening tools for cognition

-These are NOT evals
-MOCA, MMSE, Mini Cog, BIMS

Types of skill learning

-Generalization: skill from one context to another
-Tranfer: strategy of one task to another

Motor learning

-doing the activity is a good answer
-any type of cueing is a good answer

Allen Cognitive Level 1 Awareness

Total assistance 24/7 care
-fleeting nonselective attention

1.4 location stimuli
1.6 rolling in bed
1.8 raising body parts

Single sensory activities

Allen Cognitive Level 2 Large body movements

Max assistance 24/7 care
-attention to 3 minutes, awareness limited to posture and gross body movements

2.0 overcoming gravity/sit
2.4 aimless walking
2.6 directed walking

Multisensory activities

Allen Cognitive Level 3 Manual actions

Moderate assistance
-30 minute attention, simple tasks with set up like ADLs

3.0 grasping objects
3.2 distinguishing objects
3.4 sustaining actions on objects

Use of tactile cues

Allen Cognitive Level 4 Familiar activity

Min assistance
-attention last up to an hour, can do goal directed actions

4.0 sequencing familiar actions
4.2 differentiating features of objects
4.4 completing a goal
4.6 cut off for independent living

Visual cue

Allen Cognitive Level 5 Learning new activity

SBA
-new learning can occur

5.4 self directed learning
5.6 considering social standards
5.8 consulting with others

weekly check ins

Allen Cognitive Level 6

Independent
-plans new activities, reflect on mistakes

may seek guidance