Other Common Neurologic Disorders

pathophysiology of MS

astrocytes attack the white matter and demyelinate the CNS due to accumulation of small, hard, brown, irregularly-shaped plaques

types of MS

clinical isolated syndrome, relapsing-remitting, primary progressive, secondary progressive

difference between primary and secondary progressive MS

secondary appears like relapsing-remitting for a while but worsens over time, primary progressively worsens without remissions

why is it important to know what type of MS a patient has

it is important to know the trends of how it progresses so that we can write accurate goals

criteria for MS diagnosis

diagnosis of exclusion, MRI must show CNS lesions, progression over 1 year, confirmed with spinal tap

sxs of MS

visual disturbances, sensory disturbances, fatiguability, weakness, spasticity, pain, autonomic dysfunction, mood, ataxia, dizziness (basically anything because MS lesions can be anywhere)

first sxs of MS

visual and somatosensory disturbances

most common sxs of MS

lassitude/fatiguability

autonomic dysfunction in MS

manifests like POTS (heat intolerance, BP fluctuations, etc)

secondary health conditions due to body structure/function impairments in MS

infections, pressure ulcers, poor endurance/deconditioning

medical management of MS

disease modifying therapy, corticosteroids, other specific medications like antidepressants or gabapentin

types of disease modifying therapies for MS

beta interferons, immunoglobulins/modulators, b cell depleting therapies, stem cell transplant

standardized outcome measures recommended for MS

12-item MS walking scale, 9 hole peg test, DHI, fatigue scale for motor and cognitive funcitons, TUGCog, TIS

best evidence rehab interventions for MS

multidisciplinary rehab including PT and education

effect of strengthening and aerobic exercise on MS

does not worsen fatiguability but also does not make a difference in the long term prognosis

exercise dosing recommendations for MS

150 minutes of moderate intensity with aerobic, strength, and balance 2x/week

how to combat fatigue while exercising with MS

shorter sessions, interval format, spread training across the week

guidelines for exercising during a relapse

try to stay gently active, adjust based on sxs

pathophysiology of ALS

progressive degeneration of motor neurons in the brain and spinal cord

sxs of ALS

weakness and paralysis beginning in the hands and feet, progresses to diaphragm, pseudobulbar palsy (speech, swallowing), emotional lability (excessive), frontotemporal dementia

what is not affected by ALS

no pain, sensory loss, cardiac and smooth muscle not affected, oculomotor and sphincter muscles

how to diagnose ALS

progressive limb and bulbar weakness, EMG to show denervation, imaging and labs to rule out other disorders

structure of PT for ALS

2-3 visits every 3 months as a check in to modify braces and ADs

exercise guidelines for ALS

submax strength and aerobic are safe, avoid significant muscle soreness that affects ADLs, target unaffect muscle groups (>3/5)

hallmark signs of cerebellar dysfunction

incoordination, imbalance, a lot movement variability, impaired motor learning by sensorimotor adaptation

what is not considered cerebellar ataxia

weakness, loss of conscious somatosensation, abnormal synergies, spasticity, dystonia, chorea/dyskinesia, resting tremor

types of cerebellar damage

aquired, degenerative/non-hereditary, hereditary

cause of sensory ataxia

damage to dorsal column (light touch and proprioception)

sxs of damage to dorsal column

loss of conscious proprioception (numbness, paresthesia), inability to use proprioception

how is loss of proprioception compensated

visual, vestibular, oculomotor proprioception systems

signs of reduced proprioception

uncoordinated movements, imbalance (positive romberg), slowed postural response, drift

cause of cerebellar ataxia

damage to cerebellar peduncles, inferior olive, corticopontocerebellar pathways, spinocerebellar pathways

sxs of cerebellar ataxia

imbalance/falls, clumsiness, diplopia, slurred speech, action tremor, co-contraction to lock out joints and feel more stable, oculomotor signs

tests for cerebellar ataxia

coordination, veering gait, falls, dysmetria aor dyssynergia

consequence of cerebellar damage

cannot use error signals to update feedforward motor commands

cerebellar signs

posture instability, action tremor, incoordination, oculomotor signs

non-cerebellar signs

light touch/proprioception deficits, strength deficits, resting tremor, spasticity

how to evaluate movement features of cerebellar damage

effects of visual feedback on movement, effect of speed/DoF, assess motor learning

features of cerebellar gait ataxia

veering, LOB, difficulty stopping and turning, variable foot placement and step timing, worse when faster, WBOS

clinical scales used to rate severity of ataxia

international cooperative ataxia rating scale (ICARS), scale for assessment and rating of ataxia (SARA)

purpose of scales that rate ataxia severity

used to look at progression not guide treatment

outcome measures used to assess pts with ataxia

DGI, berg, ABC, TUG (and other core measures)

guidelines for cerebellar interventions

balance training is important, prioritize difficult long term coordinative training (high cognitive load, high reps), target proximal core stability, use multi-faceted and task-specific programs, HEP for lifelong reinforcement

what not to do during cerebellar intervention

put weights on them, treat it as a strength deficit, teach pt to stiffen joints, dont expect rapid improvements

how do patients learn with cerebellar damage

reward-based, repetition-based, explicit strategies