Stanbridge - T5 - Neuro1 - W4 - Intro to Other NS Disorders

Neurological Disorders Objectives

• Understand the etiology and staging of Alzheimer's disease.
• Communicate effectively with individuals with Alzheimer's disease who have various cognitive limitations.
• Discuss the causes, grading, clinical manifestations, and recovery protocol for concussions.
• Describe the incidence, etiology, and clinical manifestations of persons with Huntington's Disease, encephalitis, encephalopathy, myasthenia gravis, and Parkinson's Disease.
• Understand the typical medical and surgical management of persons with Huntington's Disease, encephalitis, encephalopathy, myasthenia gravis, and Parkinson's Disease.
• Discuss a core set of outcome measures for the neurologic population.

Alzheimer's Disease Etiology

• The exact cause of Alzheimer's Disease is unknown.
• Possible factors include high levels of aluminum in brain tissue.
• Possible factors include lower levels of neurotransmitters.
• Genetic inheritance, autoimmune disease, and viruses are also being researched as potential causes.

Alzheimer's Disease Known Risk Factors

• Age is know risk factor to alzheimers
• Genetic factors
• Other risk factors include level of education.
• Being biologically female
• History of head injury
• Exposure to heavy metals and toxins
• Positive family history
• Trisomy 21

Alzheimer's Disease Stages

• Early Stage: Changes in higher cortical function, difficulty learning new tasks/names, memory/concentration issues, increased difficulty planning/organizing, forgetting recently read material, and difficulty in social/work settings.
• Mid-Stage: Forgetfulness of events and personal history, inability to recall information about themselves, loss of orientation, bowel/bladder incontinence, personality/behavioral changes, depression, poor judgment, and difficulty performing self-care.
• Late Stage: Requires 24/7 care, loss of awareness of recent experiences, difficulty communicating, physical changes like rigidity/bradykinesia leading to shuffling gait, and vulnerability to infections, especially pneumonia.

Alzheimer's Disease Treatment

• There is currently no cure for Alzheimer's Disease.
• It is a progressive and fatal disease.
• Therapy focuses on maximizing remaining function, family and caregiver training.

Alzheimer's Disease Aggressive Behavior

• Do: identify the cause, ensure safety (themselves/others), shift focus, speak calmly and reassuringly, and give personal space.
• Don't: argue, force an issue, restrain the patient, or say "no."

Alzheimer's Disease Confusion with Time or Place.

• Do: Use simple explanations, provide photos/tangible reminders,redirect the person and Create a sense of safety.
• Don't: Give lengthy explanations, or try to reason with them.

Alzheimer's Disease Poor Judgement or Cognitive Problems

• Do: Be encouraging and reassuring, provide distraction when needed, clearly state what you want them to do, and find the source of the behavior.
• Don't: Question their ability, argue with them., cause anger or make them defensive by doubting them publicly, or tell them they are being "inappropriate" or "confused."

Concussion Definition

• Termed mild traumatic brain injury (mTBI) because it is usually not life-threatening, all brain injuries, including concussions, should be taken seriously.
• According to the CDC, a bump, jolt, or blow to the head or body causes the brain to bounce or twist inside the skull creating chemical change in the brain.

Concussion Symptoms

• Observed signs of concussion: impaired recall of events before or after impact, confusion regarding assignment/position, appearing dazed/stunned, uncoordinated movements, slow responses to questions, temporary loss of consciousness, and mood/behavior changes.
• Reported Symptoms: Headaches or pressure in the head, nausea or vomiting Balance issues or dizziness Blurry or double vision Sensitivity to light or noise Cognitive problems-confusion, concentration, memory

Grades of Concussion

• Grade 1: Person is confused, dazed, and experiences difficulty in following directions and thinking clearly; the individual remains conscious. Symptoms resolve in 15 min.
• Grade 2: Person is conscious but develops amnesia and the symptoms last longer than 15 min.
• Grade 3: Person is unconscious for several seconds or minutes and has observable change in physical, cognitive, or behavioral function.

Post-concussion Syndrome

• Some people can experience persistent memory, concentration, and mood issues, as well as headaches, fatigue, dizziness, insomnia, and extreme drowsiness for several weeks to months.
• Individuals should avoid actions that put them at risk for repeat concussions until symptoms subside because of the Consequence: risk of Second-Impact Syndrome (SIS).

Second Impact Syndrome

• Acute and often fatal brain swelling occurs when a second concussion arises before complete recovery from the prior concussion, due to vascular congestion and increased intracranial pressure.
• Young athletes often return to high-contact sports to quickly and the CDC reports an average of 1.5 deaths/year from sports concussions.

Chronic Traumatic Encephalopathy (CTE)

• CTE is a degenerative brain disorder due to repeated head impacts.
• Usually affects athletes in contact sports, military personnel and anyone who participates in sports and activities.
• Preventing head injuries is the best way to address this medical state.

Concussion Protocol and Physical Therapy

• Protocols include both physical and cognitive rest.
• Implement Exercise ASAP
• Follow this with moderate intensity aerobic exercise to reintroduce the body movement
• Start with 20 minutes of brisk walking or bike set with mild resistance to avoid headache or dizziness
• Stop exercising and try again the following day if there are any issues.

Recovery from Concussion

• REST: It is advised to limit physical/cognitive activities, good sleep and naps and ask for written instructions about when you can safely return to work, school or other activities, such as driving.
• Light Activity: Begin with "non-strenuous" activities and avoid activities that reproduce your symptoms or get worse
• Moderate Activity: Return to most “regular activities” If your symptoms do not get worse during an activity, then that activity is OK

CDC 6-Step Return to Play Progression

• Step 1: Back to regular activities
• Step 2: Light aerobic activity- increase athlete's HR, for about 5-10 minutes, with NO weight-lifting
• Step 3: Moderate activity- Continue with activities to increase HR w body or head movement & Moderate-intensity weight-lifting
• Step 4: Heavy, non-contact activity- Sprinting/running and high-intensity stationary biking/weight-lifting routine, with only non-contact sport-specific drills
• Step 5: Practice and full contact- Return to practice and full contact in controlled practice
• Step 6: Return to Competition

Steps to help speed up recovery

• Avoid activities that may put one another another head injury.
• Avoid electronics and loud music before bed.
• Regulate sleep by creating a sleep wake schedule.
• Seek medications to help.
• Connect with love ones for optimal recovery.

Encephalitis Information

• Encephalitis is an acute inflammatory brain disease caused by viruses carried by mosquitos, ticks, or human herpes simplex.
• Can result in damage to the Pia mater, arachnoid layer and cerebral circulation.
• Incidence affects 10-15 people per 100,000 each year in the US (NIH, 2024).

Encephalitis Symptoms

• Headache
• Nausea/Vomiting
• Altered consciousness
• Agitation
• Stiffness of back and neck if meninges are involved
• Focal neurologic signs based on area of the brain, like ataxia, hemiplegia or aphasia

Encephalitis Treatment

• Treatment will depend in the cause of the virus, but there is no definitive treatment.
• Suportive care is recommended based in the type of infecting agent, and will range fromn good to moderate. Approximately 50% of cases have neurologic symptoms and recovery can be variable (NIH, 2024).

Encephalitis implications for PTA

• Maintain all isolation/infection control procedures.
• Confusion or agitation should be assesed using Rancho Los Amigos Levels of Consciousness (PTA 1015).
• The patient requires consistent vitals monitoring, patient should be positioned out of abnormal postures.
• Reduce any headache symptoms by keeping the room dark.
• Consider if a client is presenting with seasonal mosquito and tick bites (Goodman, 2024).

Encephalopathy

• A group of conditions causing fundamental brain dysfunctions like confusion, memory loss, personality changes, hallucinations, involuntary muscle movements and potentially coma (Cleveland Clinic, 2024).

Types of Encephalopathy

• Anoxic due to cardiac arrest
• Chronic Traumatic due to repetitive hits to the head
• Hepatic because of liver disease
• Hypertensive or high blood pressure problems
• Metabolic and Metabolic diseases
• Toxic can come from drug use or poison

Encephalopathy Implications for the PTA

• A very common factor is hepatic encephalopathy
• Protect unsteady patients from falling
• Be alert for Gl Bleeding
• Beware of skin breakdown
• Always provide rest breaks
• Monitor for signs of anemia or tachycardia (Goodman, 2024).

Myasthenia Gravis Etiology

• Chronic autoimmune neuromuscular disease with enlarged thymus.
• Associated with diabetes, RA. lupus, and other immune disorders.
• Severity ranges from mild to sever

Myasthenia Gravis Signs and Symptoms

• Extreme fatigue and skeletal muscle weakness can fluctuate within minutes or over an extensive period of time.
• Can begin Ocular muscles affected first.
• Half of all patients show ptosis and diplopia.
• Patients can show symptoms of Cranial nerve involvement along with Dysarthria and/or Dysphagia.
• Patients can have Shortness of breath Weakness in muscles in extremities and neck.
• Also watch out for Myasthenia Gravis "crisis" – a medical emergency due to respiratory muscle distress.

Myasthenia Gravis Crisis

• A medical emergency due to respiratory muscle distress that can require a ventilator during a crisis.

Myasthenia Gravis Treatment

• There is currently no known cure but treatments are available to manage symptoms.
• These high quality treatments may include Thymectomy, Monoclonal antibody, Anticholinesterase medications, Immunosuppressive drugs, and Plasmaphoresis and IVIg.
• PT will focus on energy conservation and isometic strengthening

Parkinson's Disease

• It is a chronic, progressive neurological condition that affects the motor system.

Parkinsonism

• Parkinson’s Disease is part of a bigger group of disorders called "Parkinsonism".
• Primary Parkinsonism = Parkinson Disease = Idiopathic Parkinson Disease (IDP).
• Other categories include Secondary Parkinsonism and Parkinson-plus Syndrome.

Primary Parkinson's Disease

• Accounts for 85% of all cases of Parkinsonism.
• The most common age range is 50-79 with an incidence rate of 20.5 per 100,000 in U.S. with advancing age.

Primary Parkinson Disease: Etiology

• Multifactorial: many factors contribute to its clinical entity. Risk factors include:
  • Increasing age
  • Genetic origins
  • Environmental toxins such as pesticides/herbicides

Parkinson's Disease: Pathophysiology

• Symptoms result from a decrease in dopamine, a neurotransmitter, stored in the substantia nigra (basal ganglia) which can be both inhibitory and excitatory, causing slow movements.

Parkinson's Disease: Acetylcholine and Muscles

• Dopamine is supposed to inhibit acetylcholine at times to balance the amount of muscle contraction when using an excitatory NT
• Decrease in dopamine = decreases muscle inhibition
• Too much acetylcholine will increase muscle contraction on both sides of a joint, causing Rigidity and Bradykinesia

Parkinson's Desease: Basal Ganglia

• Primary responsibilty is regulation of posture and movement
• Lesions here change the character of movement rather than produce weakness or paralysis

Parkinson Disease Clinical Features

• 4 primary features of Parkinson’s Disease include Tremor, Rigidity, Akinesia/Bradykinesia, and Postural Instability.

Tremor in Parkinson's Disease

• Is often the first sign of primary PD, beginning unilaterally and progressing bilaterally.
• Resting tremor is often Described as “pill rolling” in the hand (4-7 beats per second)
• It can also be in the postural muscles in the head, neck, trunk, and face but rarely interferes with ADLs.

Parkinson's Disease Rigidity

• Rigidity is defined as resistance to passive movement regardless of speed such as trunk Rigidity, which impairs breathing and phonation.
• Causes increased energy expenditure and can be found in the trunk/extremities.
• Two main types: lead-pipe and cogwheel.
• Cogwheel Rigidity causes jerky, ratchet-like, tense & let go (combo of lead-pipe and tremor)

Parkinson's Disease Akinesia

• Akinesia means = inability to start movement; freezing episodes can occur by Environmental changes like different surfaces, doorways, distractions, transitions.
• Dysphagia = Impaired swallowing

Bradykinesia

• Decreased amplitude of movement: Shuffling gait, slow oral movements, and small handwriting.
• Slow oral movements = poor speech, inadequate breath support
• Micrographia = small handwriting.

Parkinson's Disease Potural Instability

• This is a Loss of postural extension and is also Inability to respond to certain postural disturbances.
• The longer someone has the disease the higher their fall rate is increased, along with visuospatial deficits and difficulties processing sensory information.

Other Parkinson Desease Features

• Features include a masked Face - lack of expression and fatigue.
• Systemic Manifestations: Dementia and Bradyphrenia with slowed thought processes along with difficulties for attending to a task and concentration.

Parkinson Disease Gait

• Festinating gait = short steps with increased speed to try and "catch up" due to limited ROM & Bradykinesia and rigidity
• Narrow BOS (base of support)
• Freezing episodes

Falls and Parkinson Desease

• Parkinson disease patients are twice as likely as the elderly to fall.
• Can be predictable with Previous Falls, Disease duration, Dementia and Loss of arm swing (Martin & Kessler, 2019).

Physical Therapy Management for Parkinson Disease

• Maximize function with early interventions and knowledge knowing the disease process will progressFocus
• Prevent indirect impairments
• Reduce deconditioning, musculoskeletal changes, loss of extension & rotation and focus in posture, locomotion, general activity

Huntington's Disease (HD)

• Huntington's Disease is an inherited disease that causes neurons to break down.
• HD affects areas of the brain that control voluntary movement.
• It has a genetic origin in autosomal dominant trait.
• Estimated incidence: 3 to 7 per 100,000 people of European descent, with diagnosis between 35 and 55 years old.

Huntington's Disease Signs and Symptoms

• Movement disorder results in involuntary choreic movements
• Patients may or may not have a Mild alteration in personality, Grimacing, or protrusion of tongue
• Ataxia along Choreoathetoid movements
• Patients who can enter Late Stages of HD can have these symptoms: Mental deterioration Decreased IQ Dysphagia Incontinence Immobility and or Rigidity

Huntington's Disease Rehab Goals

• Effectiveness of aerobic exercises paired with strengthening exercises such as Aerobic exercise at moderate intensity(55 90% HRmax), Paired with upper and lower body strengthening 3x/week for minimum of 12 weeks, Will improve fitness and stabilize or improve motor function
• Gait Training for Walking Speed and Length
• effectiveness of gait training in persons with HD such One on one supervised gait training focus to improve walking speed and step length

HD

Effectiveness of balance exercises may be delivered at moderate Levels to improve posture Breating exersices Role of physical therapy on ADL's and overall care

Neuro Outcome Measures

• Upright Motor Control Test
• Trunk Impairment Scale
• Function in Sitting Test
• Orientation Log
• Brief Interview for Mental Status
• Mini Mental Status Examination
• Montreal Cognitive Assessment

Upright Motor Control Test

• Voluntary control or functional strength of the hemiparetic LL in standing: recommended for CVA.
• The scores from 3 the LE is scored from: 3 strong, 2 = moderate, 1 = weak.

Trunk Impairment Scale

• Tests static and dynamic sitting balance and trunk coordination, recommended for CVA and Parkinson's Disease.
• Scores: 0 to 23= better the score = better outcome.

Function in Sitting Test

• Determines sitting balance function and useful for Vestibular disorders and CVA
• Scores: 0 to 56 better better score = better outcome

Orientation Screen

• Assess orientation to person, place, situation and time and should be adminstered to all inpatient clients.
• The scale is rated from 0 to 4 when higher score = greater orientation.

Brief Interview for Mental Status (BIMS)

• Test to screen for cognitive decline.
• Screening test for all inpatient clients.
• 0 to 15 higher number = higher cognition.

Mini Mental State Examination (MMSE)

• Purpose: assess cognitive impairment
• Population: CVA, Parkinson Disease, Alzheimer's/Dementia, TBI older Adults
• Score: 0 to 30 higher = better cognition

Montreal Cognitive Assessment (MoCA)

• Determine cognition status to diagnose CVA, TBI, Parkinson's/Alzheimer's/Dementia, mental health clients
• Scale from 0-30 to help improve cognition.