Stanbridge - T5 - Neuro1 - W3 - NS Diagnoses PNS Anatomy

• Neurologic Interventions I (PTA 1012) covers the role of the PTA in neuro rehab and introduces other nervous system disorders.

Lecture Objectives: The Role of the PT/PTA in Neurologic Rehabilitation

• Understand the Nagi Model vs. the International Classification of Functioning, Disability, and Health (ICF) and its relationship to physical therapy practice.
• Explain the role of the Physical Therapist (PT) in patient management.
• Describe the role of the Physical Therapy Assistant (PTA) in the treatment of patients with neurologic deficits.

Nagi Disablement Model

• The Nagi Disablement Model includes the following components: disease, impairment, functional limitation, disability, and handicap.
• Disease: Pathology
• Impairment: Alteration of structure and function
• Functional Limitation: Difficulty performing routine tasks
• Disability: Significant functional limitation; cannot perform expected tasks
• Handicap: Societal disadvantage of disability
• Ex. A patient with progressive weakness presents with paralysis of the trunk and lower extremities from a T12 spinal cord tumor.
• The patient utilizes a wheelchair for mobility and requires assistance with self-care and worked as a delivery man prior to hospitalization.

International Classification of Functioning, Disability, and Health (ICF)

• The ICF Framework includes health condition (disorder or disease), body functions & structure, activity, participation, environmental factors, and personal factors.
• Health Condition: Disorder or disease
• Body Function/Structure: Physiologic processes/anatomical structures
• Activity: Difficulties an individual may have in executing a task or action
• Participation: Problems an individual may experience in involvement in life situations
• Environmental Factors: Natural environment, products and technology, services/systems/policies
• Personal Factors: Support/relationships, medications, motivation (Giles 2018)
• Ex. A patient post motor vehicle accident diagnosed with C6 complete SCI is wheelchair dependent for mobility and resides in a town without public transportation.
• He was very active in his church choir and taught Sunday school prior to his motor vehicle accident.

Role of the PT in Patient Management

• The PT conducts the initial examination and evaluation, then develops a plan of care that meets the patient's goals.
• The Guide to Physical Therapist Practice outlines the steps in patient management: examination, evaluation, diagnosis, prognosis, interventions, and outcomes.

Role of the PTA in Patient Management

• Considerations for the PT prior to assigning interventions to the PTA include:
  • Patient's condition
  • Practice setting
  • Prognosis of the patient
  • Knowledge base of the PTA
  • Insurance coverage
• The PT is ultimately responsible for the actions and treatment carried out by the PTA.
• The PTA works under the license of the PT.
• The PT must co-sign all daily notes and documentation completed by the PTA.
• The Registered Musculoskeletal Assistant (RMA) should not treat physiologically unstable children.
• The RMA should not treat when treatment is complex, requiring consistent adjustments and response monitoring.

The PTA's Role on the Health Care Team

• Primary PT/PTA
• Physician
• Occupational Therapist (OT)
• Speech Language Pathologist Therapist (SLP or ST)
• Recreational Therapist
• Nursing Personnel
• Psychologist
• Social Worker
• Patient and Family
• The PTA provides therapeutic interventions to improve the patient's functional independence.
• The PTA participates in patient and family education and caregiver training.
• The PTA provides input regarding the patient's discharge plan.
• The PTA maintains open communication with all team members.

Bipartisan Budget Act of 2018

• It establishes modifiers to be used when an OTA or PTA furnishes all or part of any covered outpatient therapy service.
• It sets the stage for a payment differential that would reimburse services provided by PTAs and OTAs at 85% of the fee schedule beginning in 2022.

Patient Driven Payment Model (PDPM) Skilled Nursing

• Under PDPM, each patient is classified into a group for each of 5 case-mix adjusted components:
  • Physical Therapy
  • Occupational Therapy
  • Speech Language Pathology
  • Nursing
  • Non-Therapy Ancillary (NTA)
• Patients are assigned to a treatment category based on:
  • Clinical reason for the stay in the SNF
  • Resident's functional status
• PT and OT components collapsed into 4 clinical categories for the clinical reason for the SNF stay:
  • Major Joint Replacement or Spinal Surgery
  • Acute Neurologic
  • Non-orthopedic surgery
  • Non-Surgical Orthopedic/Musculoskeletal
  • Medical Management
  • Cancer
  • Pulmonary
  • Cardiovascular & Coagulations
  • Acute Infections
• The functional score is based on Section GG items predictive of PT/OT costs:
  • Two bed mobility items
  • Three transfer items
  • One eating item
  • One toileting item
  • Oral hygiene item
  • Two walking items
    • Each item has a score up to 4 points
• Higher points are assigned to higher independence levels.
• The functional score is added to the clinical category.
• An example shows (CMS.gov) the Section GG Items included in the PT and OT Functional Score.
• Cognitive Score is assessed using either:
  • Brief Interview for Mental Status
  • Staff Assessment for Mental Status using the Cognitive Performance Scale (CPS) to score the staff.
• PDPM Cognitive Score Classification Methodology includes cognitive level, BIMS score, and CPS score.
• The following has an effect on reimbursement: Primary Dx (example Cerebral Infarct), PT/OT clinical category (example Acute Neurologic), GG Items/Functional Score + Cognitive score(example: cognitive score BIMS of 10).
• How PDPM impacts the PTA working in a SNF: adjustments to faculty/therapy - more/ less full-time, variable among SNFs
• Misinterpretation of group & concurrent therapy cap has increased group & concurrent therapy.
• Group therapy (CPT code 97150): A session where a therapist treats 2-6 residents performing the same/similar activities.
• Concurrent therapy (CPT code 97032): treatment where a therapist treats 2 residents at same time performing different activities
• PDPM has a 25% limit of billed PT/OT minutes being concurrent or group therapy

Introduction to Multiple Sclerosis (CNS Disorder)

• Multiple Sclerosis: A chronic, debilitating disease resulting from demyelination of the nervous system.

Neurological Disorders Lecture Objectives: Multiple Sclerosis

• Describe the incidence, etiology, and clinical manifestations of persons with Multiple Sclerosis.
• Understand the typical medical and surgical management of persons with Multiple Sclerosis.

Multiple Sclerosis: CNS Disorder

• Epidemiology:
  • Onset between 20-40 years of age.
  • Females have a three-time higher incidence than males.
  • More than 1 million people in the U.S. are affected.
  • Higher rates are in the US, Canada, and Northern Europe.
• Etiology:
  • Mostly categorized as an autoimmune disorder
  • Genetics influence the risk
  • Risk factors: smoking and low vitamin D
• Pathophysiology:
  • Patches of demyelination appear in the white matter of the brain and spinal cord.
  • Myelin-producing cells get destroyed, inhibiting re-myelination of the axon.
  • Inflammation accompanies the destruction.
  • Nerve fibers can also be destroyed.
  • Review: Myelin allows for increased speed of conduction; reduced responsiveness when myelin is absent.

Clinical Features: Multiple Sclerosis (CNS Disorder)

• Sensory Symptoms:
  • Paresthesias ("pins and needles")
  • Dysesthesias (squeezing sensation around the torso)
  • Pain and itching
• Visual Symptoms:
  • Decreased acuity
  • Neuritis = inflammation of the optic nerve that causes graying or blurring of vision
  • Diplopia = double vision
  • Nystagmus = involuntary oscillating of an eye
    • https://www.youtube.com/watch?v=RNPre4PdaOQ
• Motor Symptoms:
  • Motor weakness (corticospinal tract involvement)
  • Incoordination of alternating movements (i.e., flexion and extension resulting in impaired walking)
  • Poor balance
  • Spasticity
  • Ataxia
  • Postural Tremor
  • Difficulty coordinating oral movements interfering with speaking and swallowing
  • Scanning speech (slow, long pauses, lack fluidity)
• Fatigue:
  • Most frequent reported problem
  • No physiologic reason
  • Worsened by heat or increased temperature
  • Closely linked to depression (MS fatigue improves when depression is alleviated)
    • Uhthoff phenomenon (blurred vision and increased paresthesias when overheated)
    • Overwhelming fatigue
• Cognitive Impairment:
  • Half of patients with MS experience some type of cognitive impairment mild to moderate in severity
    • Problems solving, short-term memory, visual-spatial perception, conceptual reasoning
  • Only 10% have it severe enough to interfere with ADLs
  • Lesions in the frontal lobe can affect judgment and reasoning
  • Emotional lability
• Autonomic Dysfunction:
  • Patients with MS may experience impaired reflex control of the bowel and bladder. This leads to urinary retention, nocturia, and constipation.
  • In later stages they may experience complete loss of bowel and bladder as well as sexual dysfunction.

Disease Course: Multiple Sclerosis (CNS Disorder)

• There are 4 major types of MS:
  • Clinically Isolated Syndrome (CIS): first episode of neurologic lasting for 24 hours.
  • Relapsing-remitting: Definable exacerbations and remissions (most common)
  • Primary progressive: Relentless progression without relapses (10% of cases)
  • Secondary progressive: Begins with relapses and remissions and then becomes progressive with only occasional relapses.
• Diagnosis (3 criteria)
  • Clinical evidence of at least 2 lesions in the brain, spinal cord, or optic nerve AND
  • Evidence that damage occurred at different times AND
  • Rule out all other possible diagnoses
  • Sometimes used to speed up diagnosis: Cerebral spinal fluid shows presence of oligoclonal bands and myelin protein

Medical Management: Multiple Sclerosis CNS Disorder

• There are 4 injectable medications have been developed in the past several year (CRAB) reduce inflammation at the lesion sites and reduce frequency of attacks
  • Copaxone: Blocks T cells that damage myelin
• Interferons (a naturally occurring ptotein that is used to prevent excessive inflammatory responses (this protein is at lower levels in people with MS)):
  • Rebif
  • Avonex
  • Betaseron
• Common Side Effects of “CRAB” medications: Nausea, Increased bleeding, tiredness, confusion, Allergic reaction, Jaundice
• Additional Effects of “CRAB” medications: Anxiety, hallucinations, depression, aggressive behavior
• Cortisone/corticosteroids – shortens acute attacks
• Ditropan and Flomax – treat bladder dysfunction
• Colace and Milk of Magnesia – treat bowel dysfunction
• Prozac, Wellbutrin, Zoloft – treat depression
• Klonopin – treats severe tremors
• Adderall, Provigil- treat fatigue
• Dantrium, Baclofen, Klonopin- treat spasticity
• Lyrica, Neurontin – treat pain
• Goals
  • Minimize progression
  • Maintain functional independence
  • Prevent and decrease complications
  • Maintain respiratory function
  • Conserve energy and manage fatigue
  • Patient/family education

Neuroanatomy: Peripheral Nervous System (PNS)

- At the end of the lesson will be able to:
    - Identify significant structures and functions within the spinal cord
    - Identify significant structures and functions within the peripheral nervous system
    - Discuss components of cervical, brachial and lumbosacral brachial plexus

• The PNS contains nerves that lead to and from the CNS
• It includes cranial nerves that exit from the brain stem, and spinal roots exiting from the spinal cord, and peripheral nerves.
• The PNS is divided into Somatic Nervous System (SNS) and Autonomic Nervous System (ANS).

Somatic Nervous System (SNS)

• A voluntary nervous system
• Responsible for skeletal and muscle contraction
• There are 12 pairs of cranial nerves and 31 pairs of spinal nerves.
• Cranial nerves are sensory or motor
• Peripheral Nerves
  • 8 Cervical
  • 12 Thoracic
  • 5 Lumbar
  • 5 Sacral
  • 1 coccygeal
• C1-7 exit above the corresponding vertebrae
• C8 and below exit below the corresponding vertebrae
• Nerves that control sensation of innervate a region of skin are dermatomes

Cervical Plexus

• Composed of the spinal nerves c1-c4
  • primarily innervates the muscles of levator scapulae, neck as well as portions of the trapezius and sternocleidomastoid
• Is Composed of the spinal nerves C5-T1
• Provides sensory and motor innervation from more than one spinal root level (separates & reunites)
• Innervates most of the upper extremity musculature
  • Musculocutaneous
  • Axillary
  • Radial
  • Median
  • Ulnar

Lumbosacral Plexus

• Composed of the spinal nerves L1-S3
• Innervates the muscles of foot, lower legs and thigh Does NOT operate and reunite in the manner of the brachial 8 roots operate 6 primary nerve
• Obturator nerve
• Femoral
• Superior gluteal nerve
• Inferior gluteal.
• Common peroneal n(sciatic nerves)
• Peripheral nerves contains z types:

Types of Nerve Fibers

• Motor has a large body for the cell, as small dendrites and a large axon.
  • The long axon eventually joins and becomes apart of peripheral nerve then into the motors end to plate of msucle
• Sensory (Afferent):
  • Has dendrites to the muscle , skin and golgi of a tendon.
  • Axon proceeds from the spinal nerve and to the doral horn of spinal cord.
  • Transmits information from spinal cord and periphery

Autonomic Nervous System(ANS)

• Has:

  • Involuntary
  • Innervates glands, smooth muscle and myocardium
  • Purpose to retain internal balance
  • Regulates the PSNS and SNMS,which function antagonistically
    • Control: arterial blood pressure , heart rate,gastrointestinal functions, sweating temperatures

• Sympathetic:

  • Heart- increase heart rate and increase in contraction.
  • Involves: Constrict the Lungs; Bronchodilation; decrease mobility; contractions, decrease secretion.

Parasympathetic.

• Decreases in heart rate
  

• Broncho constriction of lung

•  Increased mobility or increased secretions, - no effect on blood vessels.
  

What happens when the PNS is injured?

• Nerves: injury is compression traction laceration chemical disease in the body, nutritional deficiencies

•   Regenerating not possible when cell body is compromised. But If the axon is injured; cell regeneration is possible through the Schwann cells.
  

•  Axon regrows by 1.0 mm each day subject to size or thickness of cells
  

• Rate depends on the injury distance to the destination.
• Lower Neurons results to cause a damage to the anterior , roots, horn or nerves.
  • Result. Flaccidity or decreased in the body, hyporeflexia muscle or decreased reflexes, atrophy.
  • Upper is damage to brain leading to issues such as

Introduction to other nervous system

Amyotrophic

• The Incidence , ETIOLOGY and information that people need
• CNS and PNS

Amyotrophic Lateral Sclerosis

• Also known as Lou Gehrigs disease

•   Rare ; causes motor neuron to not to function
  

•  Sporadic is familiar ; many are not a sporadic
  

  • cause: protein neurotoxicity of neurons.
• In every 100,000. 3-4% of people.

•   Symptoms : usually begins in late 50s but like males symptoms are muscle.
    - Clinical presentation:
       UMN : spacticity clonus
         LMW: fasculations assymetria hands to toe distal to primital. muscle stiffness sobs increased saliva depression.
  

• early moderate or late

  •   3 stage: most has week muscle a major impact to speech,
    

    • MId stages continue decreasing and difficulty
• Wheelchairs are needed, bad posture, bad muscles. Can cause the patient to die from decrease ventilation or decrease diaphragm to acessory..

Treatment Amyotrophic Lateral Sclerosis

•   No damage reversal
  

•   But FDA: for the following:
  

•    Reduce  levels. Rluzoles -delays ventilation by 2- 3 months.
  

  • Spascitity
  • cramoing for meds spascitiy

Guillain-

• Barre syndrome is inflammatory
• Dymilation of neuro cause paralyis and muscles to work
• Prior to the onset if individuals
• incidence of 3000 every state
• The is not age specific but. Linked to
• vrusc surgery

Gilliuan Barre Sundrome Patholy

• Symmetrial ascending progressive loss

•   Motor.  Sensroy invoivemtn
  

• Invoiulme diaphragm to mecaical ventiaion.

•   50 % expereince BP venous reru Tachdia arrthmias
  

• The pain is in musics dysartia is fical weekns ; DTRS

Gilliun Medical manage

• Plasmaphreis removed Red blood vells
• Intruavious
• Both: inited in two weeks to sorten the progreession.

Post-polio

• The name is late for the polymetis body is paralisy the bady • In to 19- 57 by.

1. polimels 38 39 %.weaksds of function

• Positive nerulogicaal to ekg un expalned. New. Neuorlocial
• Increased in tbe ody giant unist thdy

Other

• Clinical Features*: -Fatigue -New weakness Clinical feature cold function
• No medication has proven effective • Exercise in moderation. diet -Decrease workload -Avoid -ambulate 4.level.family

Which is thought to be decreasing the rate of. Body?

• B. motor