Full CNS - Final Exam Prep

Huntington's Disease Overview

• Huntington's Disease, is also known as Huntington's Chorea or HD.
• HD is a neurodegenerative disease.

Disease Characteristics

• HD is characterized by choreiform movements and progressive dementia.
• Chorea is defined as brief, purposeless, and random movements.
• The disease is progressive, leading to death within 15-20 years of onset.
• Neurological or psychological impairment occurs.
• HD causes involuntary movements, although rigidity can also be a feature in adults.
• Males and females are diagnosed in equal numbers.
• Symptoms usually appear between ages 35-55.
• In youth it is around 20 years and under, known as Juvenile HD (10%).
• In Late Onset HA, it occurs in 60 yrs + (10%).
• The prevalence in North America is 4-8 cases per 100,000.

Etiology of HD

• HD is caused by a mutation in the gene for the huntingtin protein located on chromosome 4.
• The mutation results in the cytosine, adenine, and guanine (CAG) sequence replicating excessively.
• Each child of a parent with HD has a 50/50 chance of inheriting the HD gene.
• A child who doesn't inherit the gene will not develop the disease or pass it on.

Pathophysiology

• HD is inherited as an autosomal dominant disorder.
• Pathologic findings show consistent tissue changes in the brain.
• The ventricles of the brain enlarge due to atrophy of the caudate nucleus and putamen within the basal ganglia
• The caudate nucleus and putamen are within the adjacent basal ganglia.
• The ventricles enlarge due to extensive loss of small and medium-sized neurons.
• There can be a 20% decrease in volume of the brain.
• Neurotransmitters are affected due to the loss of neurons.
• The normal balance of excitation and inhibition in the basal ganglia and thalamus is disrupted.

Initial Signs and Symptoms of HD

• Physical symptoms include weight loss, involuntary movements (chorea), diminished coordination, and difficulty walking, talking, and swallowing.
• Voluntary movements impairment, affects ability to work, ADLs, communicate, and affects independence
• Cognitive symptoms include difficulty with focus, planning, and recall, impaired insight and making decisions.
• Emotional symptoms include depression, apathy, irritability, anxiety, and obsessive behavior.
• Depression may result from injury to the brain and subsequent changes in brain function.

Early Stage Signs and Symptoms

• During this stage, individuals can still function well at work and home.
• Early symptoms include difficulties with organizing routines, coping effectively with new situations, and decreased recall and decision-making abilities.
• Additional early signs include mood changes and irritability.
• Minor involuntary movements or "nervous" activity, fidgeting, twitching, and excessive restlessness might be present.
• Changes in handwriting and difficulties with daily tasks like driving can occur.

Intermediate Stage Signs and Symptoms

• Those affected experience difficulties with working and managing households.
• They are often still deal able deal with ADLs.
• More obvious involuntary movements (chorea) become more apparent, Increased difficulties with walking, coordination, and balance.
• Speaking becomes challenging with slurred speech.
• Problem-solving and thinking process more difficult, thinking process changes.
• Swallowing becomes difficult.
• Weight loss occurs because of energy expenditure from choreoathetoid movements.

Advanced Stages Signs and Symptoms

• Individuals cannot manage ADLs and require professional care.
• A decreases in involuntary movements, along with an increase in rigidity.
• There are increased difficulties in the ability to swallow.
• The ability to communicate diminishes, understanding of what is being said remains.
• Significant weight loss.
• Dementia, bradykinesia, and dystonia (involuntary mm contractions) occur.

JHD & LOHD Signs and Symptoms

• Juvenile HD follows a more rapid course where, chorea is less prominent, and may be altogether absent.

Initial Symptoms of JHD

• Slow stiff movements (rigidity), sometimes tremor
• Seizures, falls, and clumsiness.
• Contracted & rigid mms that affect the gait (especially in young children).
• Difficulties learning in school and attention deficits.
• Increase in responsive behaviors also.
• The diagnosis of Late Onset HD (LOHD) is past 60.
• Sometimes misdiagnosed because doctors believe patient is too old to develop HD (typical onset is 35-55).

Diagnosis of HD

• There is no one diagnostic test for HD.
• Diagnosis is primarily based on clinical symptoms, family history, and genetic testing.
• Other tests to assess include neurological examination, neuropsychological and psychiatric testing, MRI, CT scan and genetic counseling.
• Neurological exams test motor, sensory and psychiatric symptoms.
• Neuropsychological testing checks memory, reasoning, mental agility, language skills, and spatial reasoning.
• Psychiatric evaluations assess emotional state, behaviors, judgement, coping skills, signs of disorder thinking, and for evidence of substance.

Treatment of HD

• No cure, aims towards symptom management.
• Medications, psychotherapy, speech therapy, physical and occupational therapy can provide support.
• Medications help control chorea.
• Psychiatric medications, like antidepressants, antipsychotics, and mood-stabilizing drugs, can be used.
• Psychotherapy can be administer through a psychiatrist, psychologist or clinical social worker.

Massage and Clinical Manifestations

• Classic choreiform movements - piano-playing motions in fingers, facial grimaces.
• Can involve Trunk and dancing steps in the gait, however the ability to balance remains good.
• HD patients who develop it before age 35 frequently become bedridden after 15-20 years.
• Patients may become erratic and difficult to treat.
• Are often seen in those with sleep disorders, urinary incontinence and have normal muscle strength and tendon reflexes.

Massage Therapy Considerations

• Massage should be geared toward palliative care, HD being a debilitating disorder.
• Inquire about the most comfortable positions for the client is best.
• Positions may include using cushions to ensure comfort or using the seated/side-lying positions.
• Avoid/ cautiously apply passive stretching and joint movements.
• compromised bone integrity is frequent with mobility impairments.
• Therapist and client need to devise a code by which to communicate effectively.
• Examples are raising a finger or blinking once to state yes, to indicate yes to questions or twice to indicate no to questions.

Parkinson's Disease Introduction

• Parkinson's Disease or PD is a neurological disorder.

What PD Is

• It is a neurological disorder.
• Involves diminished basal ganglia function, tremor, rigidity, and slowed movements.
• "Neurodegenerative" refers to the degeneration of neurons, which affect all brain activity.

PD Etiology

• The cause of Parkinson's is unknown.
• It involves the destruction of brain cells in the substantia nigra.
• A brain cell structure that releases dopamine.
• As we age, Muscular movement become weaker and more erratic: walking, writing reaching.
• The substantia nigra controls muscular movements by releasing dopamine, a neurotransmitter.
• Dopamine supply decreases in Parkinson's disease due to the necrosis of brain cells in the substania nigra.

Primary Symptoms of PD

• Bradykinesia: impairment of voluntary motor control, slowness or freezing. It presents in standing up, walking, sitting down. There is difficulty initiating movements and freezing episodes when walking or startles.
• Festinating gait or shuffling gait can occur.
• Rigidity is characterized as muscle stiffness that produces muscle pain with movement.
• Tremors: often occur in hands, fingers, forearms, foot, mouth, or chin, and typically occur at rest.
• Poor Balance: results from a loss of reflexes that help posture , resulting in unsteady balance and falls.

Secondary Symptoms of PD

• Postural changes.
• Breathing difficulties.
• Excessive salivation.
• Loss of bowel/bladder control.
• Breathing difficulties.
• Anxiety, depression, isolation.
• Slow response to questions.
• Soft whispery voice.

Diagnosis & Medical Treatment for PD

• A systematic neurological exam assesses reflexes, muscle strength, coordination, balance, and other motor functions to diagnose for PD and needed treatments.

Common Medications For PD

• Levodopa (Sinemet) & Entacapone (Comtan) – helps improve the effectiveness of levodopa
• Dopamine agonists (mirapex) tries to stimulate the bodies natural production of dopamine

ROOM Testing in PD

• Usual ROM and strength testing protocol attempted
• AF ROM should reveal decrease in ROM if rigidity present
• P ROM will reveal uniform resistance in the flexor and extensor groups acting on affected joints
• May reveal cogwheel rigidity (intermittent resistance)
• R ROM will not be useful if rigidity present

Special Tests for PD

• Sensory testing results vary depending on the clients sensory impairment
• for light touch
• deep pressure
• pain/temperature perception
• two point discrimination
• proprioception
• Specific orthopaedic tests depending on the complaint. Bradykinesia Test: positive test is movement becomes slower & more difficult

Contraindications for PD

• Prolonged vigorous or painful techniques are avoided ( no stimulating the SNS)
• Areas sensitive to touch are avoided
• Pressure and hydro are modified in area of altered sensation
• Positioning, techniques, hydro are modified if hypertension present.
• Hypotension is a threat due to autonomic dysfunction. (watch during position changes)
• Don't hold down tremors

Treatment Goals for PD

• Maintain proper alignment
• Decrease SNS firing
• Decrease edema if present
• Maintain tissue health
• Decrease pain
• Address postural changes and muscle imbalances
• Limit contractures
• Reduce constipation
• Address diaphragm muscles
• Maintain thoracic mobility
• Encourage whole body integration

Homecare for PD

• Encourage relaxation with diaphragmatic breathing
• Regular, moderate exercise can improve motor control
• Encourage them to continue with ADLs
• Maintain functional ability by moving joints through simple ROM, and doing balance activity. E.g. Sidelying do retraction/protraction, trunk rotation exercises

Description of Multiple Sclerosis

• Multiple Sclerosis or MS is a progressive immune disease.

MS Overview

• Demyelination of the nerve occurs resulting in scar tissue formation that affects nerve transmissions in widely scattered areas of the brain and spinal cord.
• Starts with an inflammatory process, followed by the loss of myelin that surrounds the nerve axons.
• Scar tissue, or sclerotic plaques, will develops in the sites of demyelination, which slows, and disrupts or blocks transmissions of nerves resulting in more severe symptoms if plaque formation.
• Typically strikes people during a very active times in life.
• Has average onset between 20 and 40 years of age.
• Occurring as early as 15 and as late as 45.
• Women are slightly more affected than men.

Etiology of Multiple Sclerosis

• Genetic predisposition is linked but this is not an inherited disease.
• Present in 25%-30% of monozygotic twins whose have an increased a risk if a first degree relative also has it.
• Environmental factors include where someone lives.
• The farther north, the more at risk.
• Can stem from viral infections such as measles, canine distemper, human herpes virus-6, Epstein-Barr and Chlamydia pneumonia.
• The viral infection causes overactivity of the immune response which leads to demyelination of the axons.
• Immunological factor Abnormal response of damages the CNS. T cells & B cells can causes an autoimmune response attacking the myelin

Diagnosing Multiple Sclerosis

• It is difficult to diagnosis, particularly in the early stages.
• Takes tests to see results of a medical history and neurological examination.
  -Tests might include: MRIs, Evoked Potentials (EP), Lumbar puncture (LP), optic nerves examination.
• Doctors looks for evidence of damage in at least two separate CNS areas.
  • Areas include the brain and spinal cord.
• Evidence that damage occurred at different points in time.
• Other possible diagnosed should be ruled out too for accuracy.

Types of Multiple Sclerosis

• Clinically Isolated Syndrome, Relapsing-remitting MS, Secondary progressive MS, and primary progressive MS.

Clinically Isolated Sydrome (CIS)

• Is the earliest stage.
• Refers to a only single episodes containing neurological symptoms to be related.
• Evidence of abnormality in a brain or spinal cords.
• Experiencing this type may or may not develop MS, changing its diagnosis. When multiple attacks occur it will diagnosis a relapse or remitting MS.

Relapsing-Remitting MS

• Most common.
• Unpredictable but defined with relapses from flares, exacerbations by getting worse with relapses. In between relapses, recovery will range with nearly the same function or remissions.

Secondary Progressive MS

• Is from the evolution from transitional into secondary progressives. This phase has progressive but less fewer relapses and is often associated with minor remissions and plateaus.

Primary Progressives MS

• Characterized by slow accumulations of disability without relapses. It will stabilize for a period of time with a minor of temporary improvements with out periods or remission and nearly 15% of MS patients are diagnosed.

Multiple Sclerosis Signs & Symptoms

• Signs & Symptoms depends on the location of the lesions in the CNS.
• Lesions are often on the brain system with affect with the cerebellum and spinal cord.
• White matter is affected.

Optic and Trigeminal Nerve Effects

• There is visual acuity and a colour blindness to colour visual defects the patient with be affected.
• A total blindness with the optic nerve is uncommon.

Specific MS Signs and Symptoms

• Commonly fatigue and spasticity, weakness and impaired proprioception.
• Vertigo, altered posture and circumducted gait.
• The person could have a Bladder dysfunction and potential UTIs due to this. Speech disturbance from Dysarthria to slurring and possible mood swings that are euphoria and depression.

Exacerbating Symptoms are:

• Vitamin deficiency, Amalgam dental fillings, food and stress.
• Heat and possible Emotional upset can occurs too.

Multiple Sclerosis Contraindications:

• Deep techniques of friction and vigorous work.
• Techniques that cause SNS increasing a clients fatigue.
• Decubitus ulcers from being in positions and redness/inflammation referral would be needed for client.

Assess and Goals:

• Check of the clients past history/intakes with other possible infection that might influence the clients fatigue and look at diminushements and perceptions.
• To assess: ROM tested well as sensory.

Multiple Sclerosis Goals of Massage:

• Want to prevent fatigue, decreasing SNSs, prevent the tissue and decreases the edema.
• Important to address postural change and Secondary condition with contractions.
• Address limitations of ROM that can effect their lifestyle and comfort.

Thera/Homecae in MS

• Encourage ADLs to the level of ability and suggest movement rehab programs.
• These movement may include yoga and tai chi if the client has issues shifting weights.
• Swimming and walking for good exercise.
• Modifies weights must take place in the cool environment
• Submaximal resistance
• Patient education so can aware of health and self drainage.

Amyotrophic Lateral Sclerosis (ALS) Overview

ALS, also known as Lou Gehrig's Disease, is a progressive neurodegenerative disorder.

ALS Pathophysiology

• It is a progressive and fatal neurodegenerative disorder, for which there is no cure.
• Gradual paralysis due to degeneration and scarring of the motor neurons in the lateral aspect of the spinal cord, brainstem and cerebral cortex.
• Upper motor neurons from the brain synapse with lower motor neurons in the brainstem and SC
• Lower motor neurons send nerve impulses to contract muscles
• Motor neurons gradually breakdown and die = muscles become weak/ atrophied leading to paralysis.
• NOT affected: areas of the brain controlling coordinated movements (cerebellum) and cognition (frontal cortex) (see next slide)
• About 80% of people die with in 2-5 years of diagnosis, some can live 10+

Note On Cognitive Function

• 30 to 50% of people experience cognitive/behavioural difficulties.
• Displaying inattention or difficulty with facial/reading comprehension.
• Verbal communication difficulties, obsessive etc.
• It is not advised to associate symptoms with a diagnosis of cognitive impairment without clinician support.

Etiology of ALS

• Exact cause of ALS is unknown/no cure although, cause is unknown; there is multi-factorial origins based on mutations.
• The disease occurs 20% more in men- Some research has linked mutations on the gene that produce SOD1 enzyme with ALS, this is linked with ALS.
• SOD1 enzyme is a antioxidant and damage caused by free radicals.

ALS Risk Factors

• Heredity: 5-10% is passed on from parent to the child. This gives the offspring a 5-/50 chance of development.
• Age: Risk increases with age, with the most common onset between ages 40 and 60.
• Sex: Before age 65, men are slightly more at risk than women. This disappears after 70.
• Genetics: some studies show similarities in genetic variations; Familial ALS some some in Sporadic ALS; may be more susceptible.
• Smoking: Greater incidence for women, especially post menopause.
• Military Service: Studies indicated those that are involved have a higher risk.
• The cause is still relatively unknown.
• Enviornmental toxin exposure like chemical.

Types of ALS

• Sporadic ALS: Most common, can affect anyone, most often affects people between the ages 40-60.
• Familial ALS: From parent to child, 5%-10% of cases are inherited - the rest are unknown.
• Has three main types with bulbar early symptoms in corticobulbar area of brainstem are affected.

ALS - Early Symptoms

• The early Symptoms may be as easy As Tripping and Dropping things!
• Other easy signs to point of include slurred speech, difficulty in digestion and weightloss.
• May show issues with muscle tones which also have shortness of breath associated and increase decrease to the reflexes.

Symptoms of ALS

• Lack of sensation and Speaking as well problems will show that can effect their breathing or with eating.
• Patients show mental decline with anxiety, depression, aggression with the dementia.
• Upper motor Neurons: Tight stiff muscles causing Hyperreflexia w/ Positive babinski's sign.
• Lower Motor Neurons: Muscle Weakness/Muscle cramp and Fleeting.

Other Symptoms

• EMG are given with these types of diseases so you test this out in real life with others/Rest!
• MRI's helps that to ELIMINATE tumors or problems that the patient is going through.
• Muscle biopsy is given too.

Medical Treatment

• Riluzole is given which helps to give patients 3-6 months and drugs given to control these spastic
• Edaravone is in intravenous is given and depression and with controlling the outbursts.

Other Treatments

• Physical and Speech Therapy is an option as with Breathing exercise with psychological with social work.

Massage Treatment

• Prevent respiratory complications; respiratory failure and inability to eat are final stages of ALS.
• Spasticity contributes to weakness – consistent slow stretching that decrease tone may benefit.
• Cramps respond to daily stretching.
• Ankle dorsiflexion is lost before loss of strength in plantarflexion.
• Hamstring strength appears to correlate with walking and the decrease is parallel with the loss of walking ability.
• Contractures should be routinely stretched taking care to support the joints as there is minimal control of muscle activity in late stages. Abdominal muscles helping increase inspiration when diaphragm and intercostal muscles become weak.

Massage Treatment Continued

Outcomes may include

• Maintain function of respiratory muscles.
• Decrease stiffness / maintain ROM / prevent or decrease contractures.
• Promote relaxation / improve mood.
• Maintain joint health.
• Prevent or reduce edema.
• Prevent deep vein thrombosis.
• Promote muscle function.
• Decrease pain.

Transfer Techniques General Guidelines & Considerations

• Review these for transfer and the safety is first priority.
• Ensure that all assist tools and devices are prepared as understand with to happen.
• Must value and have respect for the client.
• Act as a leader than be not confrontal, and should listen the clients.
• Take all to make well and follow the 10 step.
• Before starting anything get all to do transfer:

Transfers and its Steps

• Choose the right that is right and make sure they will be apart of.
• Make sure the patten is to be aware and to tell the patient to follow the rest.
• Make sure the wheels are locked and take away the feet for safety.
• Use weight to momentum to the unit as well like 123 LIFT!
• Must be safely aborted and avoid lifting away with the waste!

Bed Mobility

• Count of rocking with the patient.
• Have the bottom be able to shift with should and pelvic girdle.

Lateral shift

• Shift to to 3 shift the weight leg weight away from the weight you are shifting/gently are gently.

Trans and Bed with Up

• 124 with patients and the helping with the guideness

Transfers/Chair

• For chair: Facing with stabilized knee with opposite motion and for the rest the weight off the knees.
• for bed: Look for all 3-5 steps and make sure to follow though.
• Make sure to pivot and keep with the side that you are putting the weight in and know what is wrong.

Side stepping

• Use knees! and lock the wheel and to pull the person though use your weight with a support.

Spinal Cord Overview

• A spinal cord injury occurs when a direct injury to the spinal cord, or indirectly from damage to tissue or blood vessels. Paralysis occurs, causing sensation loss in parts of the body.

Spinal Cord Injury Classifications

• Direct injury or damage of spinal cord tissue.
• Result of damaging surrounding tissues.
• Primary immediate damage directly caused to tissue.
• Secondary damage is damaged that happens from a side effect.
• Total sensation loss past the source or partial which causes partial lose.

Etiology for Spinal Cord injury

• Trauma: more common as well that is (41%) - 97 and diving with  quadriplegia.
• contact with football (6 in Canda, 19Uk) with high with gun shot is going.
• Vascular and radiation is a complication
• Direct that could can effect the vascular.

Specific Spinal cord Issues

• Central Cord
• Causes Hyperflexion
• Has Upper with sensory and motor and lower is less and Bowel is affected.
• Causes is is lateral for pain and temperature perception.
• For the ones like the Damage as the cord spinal will the hyper from is bilateral to have no loss.

Types of Spigelia as the Injury

• The injury may be within any of sacral that helps. If not need from to help with ventilator from c1 t ock d3 well if diaphragms.
• If can get c6 is some with dressing and feeding and if get t1 then to be intact

Type of Plegia

• A paralyses at one point then muscle.

Autonomic as the reflex

• People at this generally are those with a higher reflex than others.
• A higher then 6 is generally more with the pains within the blood.
• A medical emergency to think.

Massage for SCI

• Most clients are on the wheel and to help with the abilities.
• Avoid any hard point that can lead with those that be for fractures.

Rood's Approach

• Designed as more from which are slow to help from the tone.

What does this do do for us?

• Helpful improve ROM, reduce tone and improve focus.

Types of tech

• In order this the proximal and distal as then 3-5 time with 3-5 min.
• Facilitating the tech as the is to help for those at a distal to.

Facilaatory technique,

• Cutaneous brushing distal to proximal. the are more from which to follow.

###Facilitatory for Light to Stimulation:

• A of and from Acing and other light to the receptors to help.

###Facilitory technique

• A quick stretching from what help can improve quickly and from all points and can help reduce.
• Use all types of pressure to cause help

###Inhibitory techniques

• Slow and rocking with vestibular will help and neutral form warmth.
• From the to go in a direction the body.
• With of Rood with time and fluidity has all those that need help and the client, The Rood with time and fluidity is what to incorporate.

PNF Patterns

• Used or be used for these functions in the with the body to use them right!
• As the used can do is be from one to sensory!

PNF Procedure/ How To

• How and are of used so how you play in the time at which these things can effect.
• Know the to give help of the motor pattern for patients.
• All has to be done in a way that has control.

Methods (Cont)

• The important in a pattering is what to help but are is what to are good at with the that all are not good to help or not. to do.
• Has to be important to for the body and give one a what if needs for their.
• The inters of help for them!