Neurologic Physical Therapy 1 Module #1 Student Activity Sheet PDF

Neurologic Physical Therapy 1 Module #1 Student Activity Sheet Name: _____________________________________________________...

Neurologic Physical Therapy 1 Module #1 Student Activity Sheet Name: _____________________________________________________ Class number: _____ Section: ____________ Schedule: ________________________________ Date: _____________ Lesson title: DIAGNOSIS OF NEUROLOGICAL DISEASE Materials: SAS, Module, pen and notebook Learning Targets: At the end of the module, students will be able to: 1. Understand the fundamental principles of neurological References: interview in the scope of subjective assessment of Ropper, A. et al., (2014). Adam’s and specific patient’s history. Victor’s Principles of Neurology. Boston, 2. Grasp the relevance of taking a proper neurological and Massachusetts, USA: McGraw-Hill. general physical examination. 3. Explain the different conventional modes in the Kasper D.L. et al., (2015). Harrison’s assessment of the cause of patient’s symptoms. Principle of Internal Medicine. Boston, 1. Massachusetts, USA: McGraw-Hill. Lowenstein D.H.et al., (2015). Approach to the Patient with Neurologic Disease. USA: McGraw-Hill. Sullivan, S.B. et al., (2014). Physical Rehabilitation. USA: F.A. Davis Company. A. LESSON PREVIEW/REVIEW SUBJECT ORIENTATION (10 minutes) Everything you have worked for has been for this moment. The brain lies at the center of our personal universe. It transforms a chaotic world of hurling particles into the perception of sense and stability. In addition to creating a sensory representation of reality, the brain allows us to be aware of ourselves and others. Every nervous system process can be deconstructed into sensation, movement, emotion, memory, and communication. The brain allows humans to create, explore, interact, and yearn for something better. It contains our greatest dreams and hopes, as well as our fears and nightmares. It is where life and religion originate. It is where good and evil reside. It is where life ends. Do not misinterpret this to mean that everyone should become a Neurologist. That would be foolish, and not in the brain’s best interest. Neurology remains an intellectually exciting discipline, both because of the complexity of the nervous system and because of the insight that the pathophysiology of neurological disease provides into the workings of the brain and mind. The goal of studying this course is not to permanently transform every physical and occupational therapy student into a Neurologist. You will just be asked to study and learn the basic principles of neurology and understand the relevance of its clinical implication in the practice of rehabilitative medicine, with no obligation to necessarily remember all detailed knowledge in the end. The purpose of this subject is to help you form the right frame of mind in building a good foundation to accurately screen and diagnose different types of neurological disorders and set realistic and time-bound goals in order to provide accurate management that the patient need in rehabilitation process. This will also help you to collaborate with other healthcare professionals at the same time in order to achieve patient’s utmost function and have better quality of life. It takes a long journey to build a framework, just like as having a hard time facing the world full of uncertainties, but still, I am encouraging you to make the most out of it, then you will be This document is the property of PHINMA EDUCATION 1 of 17  Neurologic Physical Therapy 1 Module #1 Student Activity Sheet Name: _____________________________________________________ Class number: _____ Section: ____________ Schedule: ________________________________ Date: _____________ amazed at how much there is to learn. You just have to take one step at a time and this module will surely guide you all throughout the process. To know the summary of contents of this module, it consists of 23 sessions. Each session is composed of five parts (1) the subject orientation that includes the introduction of the lesson, might also include the recap of previous lessons, (2) main lesson in which all of the contents you need to know are discussed, (3) to check your understanding, in which you need to complete an activity to test your comprehension and critical thinking skills, (4) rationalization, in order for you to have better understanding on the topics you find difficult, this will serve as an additional information at the same time, and lastly (5) wrap up, this will help you to keep track on your progress and know how much work you’ll need to accomplish. Series of activities are plotted below, in order for you to be guided in completing this module. B.MAIN LESSON Neurologic diseases are common and costly. According to estimates by the World Health Organization, neurologic disorders affect over 1 billion people worldwide, constitute 12% of the global burden of disease, and cause 14% of global deaths (Table 437-1). These numbers are only expected to increase as the world’s population ages. Most patients with neurologic symptoms seek care from internists and other generalists rather than from neurologists. Because therapies now exist for many neurologic disorders, a skillful approach to diagnosis is essential. Errors commonly result from an overreliance on costly neuroimaging procedures and laboratory tests, which, while useful, do not substitute for an adequate history and examination. The proper approach to the patient with a neurologic illness begins with the patient and focuses the clinical problem first in anatomic and then in pathophysiologic terms; only then should a specific diagnosis be entertained. This method ensures that technology is judiciously applied, a correct diagnosis is established in an efficient manner, and treatment is promptly initiated. (Lowenstein, 2015) (Lozano, R. et al.: Lancet 380: 2095, 2012) This document is the property of PHINMA EDUCATION 2 of 17  Neurologic Physical Therapy 1 Module #1 Student Activity Sheet Name: _____________________________________________________ Class number: _____ Section: ____________ Schedule: ________________________________ Date: _____________ THE NEUROLOGIC METHOD: DEFINE THE ANATOMY - The first priority is to identify the region of the nervous system that is likely to be responsible for the symptoms. Can the disorder be mapped to one specific location, is it multifocal, or is a diffuse process present? Are the symptoms restricted to the nervous system, or do they arise in the context of a systemic illness? The first clues to defining the anatomic area of involvement appear in the history, and the examination is then directed to confirm or rule out these impressions and to clarify uncertainties. DEFINE THE PATHOPHYSIOLOGY - Clues to the pathophysiology of the disease process may also be presenting the history. Primary neuronal (gray matter) disorders may present as early cognitive disturbances, movement disorders, or seizures, whereas white matter involvement produces predominantly “long tract” disorders of motor, sensory, visual, and cerebellar pathways. Progressive and symmetric symptoms often have a metabolic or degenerative origin; in such cases lesions are usually not sharply circumscribed. Thus, a patient with paraparesis and a clear spinal cord sensory level is unlikely to have vitamin B12 deficiency as the explanation. THE NEUROLOGIC HISTORY: Attention to the description of the symptoms experienced by the patient and substantiated by family members and others often permits an accurate localization and determination of the probable cause of the complaints, even before the neurologic examination is performed. The history also helps to bring a focus to the neurologic examination that follows. Each complaint should be pursued as far as possible to elucidate the location of the lesion, the likely underlying pathophysiology, and potential etiologies. Other pertinent features of the history include the following: 1. Temporal course of the illness. It is important to determine the precise time of appearance and rate of progression of the symptoms experienced by the patient. The rapid onset of a neurologic complaint, occurring within seconds or minutes, usually indicates a vascular event, a seizure, or migraine. The onset of sensory symptoms located in one extremity that spread over a few seconds to adjacent portions of that extremity and then to the other regions of the body suggests a seizure. A more gradual onset and less well localized symptoms point to the possibility of a transient ischemic attack (TIA). A similar but slower temporal march of symptoms accompanied by headache, nausea, or visual disturbance suggests migraine. The presence of “positive” sensory symptoms (e.g., tingling or sensations that are difficult to describe) or involuntary motor movements suggests a seizure; in contrast, transient loss of function (negative symptoms) suggests a TIA. A stuttering onset where symptoms appear, stabilize, and then progress over hours or days also suggests cerebrovascular disease; an additional history of transient remission or regression indicates that the process is more likely due to ischemia rather than haemorrhage. A gradual evolution of symptoms over hours or days suggests a toxic, metabolic, infectious, or inflammatory process. Progressing symptoms associated with the systemic manifestations of fever, stiff neck, and altered level of consciousness imply an infectious process. Relapsing and remitting symptoms involving different levels of the nervous system suggest MS or other inflammatory processes. Slowly progressive symptoms without remissions are characteristic of neurodegenerative disorders, chronic infections, gradual intoxications, and neoplasms. (Harrison, 2015, p. 2563) 2. Patients’ descriptions of the complaint. The same words often mean different things to different patients. “Dizziness” may imply impending syncope, a sense of disequilibrium, or true spinning vertigo. “Numbness” may mean a complete loss of feeling, a positive sensation such as tingling, or even weakness. “Blurred vision” may This document is the property of PHINMA EDUCATION 3 of 17  Neurologic Physical Therapy 1 Module #1 Student Activity Sheet Name: _____________________________________________________ Class number: _____ Section: ____________ Schedule: ________________________________ Date: _____________ be used to describe unilateral visual loss, as in transient monocular blindness, or diplopia. The interpretation of the true meaning of the words used by patients to describe symptoms obviously becomes even more complex when there are differences in primary languages and cultures. (Harrison, 2015, p. 2563) 3. Corroboration of the history by others. It is almost always helpful to obtain additional information from family, friends, or other observers to corroborate or expand the patient’s description. Memory loss, aphasia, loss of insight, intoxication, and other factors may impair the patient’s capacity to communicate normally with the examiner or prevent openness about factors that have contributed to the illness. Episodes of loss of consciousness necessitate that details be sought from observers to ascertain precisely what has happened during the event. (Harrison, 2015, p. 2563) 4. Family history. Many neurologic disorders have an underlying genetic component. The presence of a Mendelian disorder, such as Huntington’s disease or Charcot-Marie-Tooth neuropathy, is often obvious if family data are available. More detailed questions about family history are often necessary in polygenic disorders such as MS, migraine, and many types of epilepsy. It is important to elicit family history about all illnesses, in addition to neurologic and psychiatric disorders. A familial propensity to hypertension or heart disease is relevant in a patient who presents with a stroke. There are numerous inherited neurologic diseases that are associated with multisystem manifestations that may provide clues to the correct diagnosis (e.g., neurofibromatosis, Wilson’s disease, mitochondrial disorders). (Harrison, 2015, p. 2563) 5. Medical illnesses. Many neurologic diseases occur in the context of systemic disorders. Diabetes mellitus, hypertension, and abnormalities of blood lipids predispose to cerebrovascular disease. A solitary mass lesion in the brain may be an abscess in a patient with valvular heart disease, a primary haemorrhage in a patient with a coagulopathy, a lymphoma or toxoplasmosis in a patient with AIDS, or a metastasis in a patient with underlying cancer. Patients with malignancy may also present with a neurologic paraneoplastic syndrome or complications from chemotherapy or radiotherapy. Marfan’s syndrome and related collagen disorders predispose to dissection of the cranial arteries and aneurismal subarachnoid haemorrhage; the latter may also occur with polycystic kidney disease. Various neurologic disorders occur with dysthyroid states or other endocrinopathies. It is especially important to look for the presence of systemic diseases in patients with peripheral neuropathy. Most patients with coma in a hospital setting have a metabolic, toxic, or infectious cause. (Harrison, 2015, p. 2563) 6. Drug use and abuse and toxin exposure. It is essential to inquire about the history of drug use, both prescribed and illicit. Sedatives, antidepressants, and other psychoactive medications are frequently associated with acute confusional states, especially in the elderly. Aminoglycoside antibiotics may exacerbate symptoms of weakness in patients with disorders of neuromuscular transmission, such as myasthenia gravis, and may cause dizziness secondary to ototoxicity. Vincristine and other antineoplastic drugs can cause peripheral neuropathy, and immunosuppressive agents such as cyclosporine can produce encephalopathy. Excessive vitamin ingestion can lead to disease; examples include vitamin A and pseudotumor cerebri or pyridoxine and peripheral neuropathy. Many patients are unaware that over-the-counter sleeping pills, cold preparations, and diet pills are actually drugs. Alcohol, the most prevalent neurotoxin, is often not recognized as such by patients, and other drugs of abuse such as cocaine and heroin can cause a wide range of neurologic abnormalities. A history of environmental or industrial exposure to neurotoxins may provide an essential clue; consultation with the patient’s coworkers or employer may be required. (Harrison, 2015, p. 2563) This document is the property of PHINMA EDUCATION 4 of 17  Neurologic Physical Therapy 1 Module #1 Student Activity Sheet Name: _____________________________________________________ Class number: _____ Section: ____________ Schedule: ________________________________ Date: _____________ 7. Formulating an impression of the patient. Use the opportunity while taking the history to form an impression of the patient. Is the information forthcoming, or does it take a circuitous course? Is there evidence of anxiety, depression, or hypochondriasis? Are there any clues to problems with language, memory, insight, comportment, or behaviour? The neurologic assessment begins as soon as the patient comes into the room and the first introduction is made. (Harrison, 2015, p. 2563) THE NEUROLOGIC EXAMINATION: There is no single, universally accepted sequence of the examination that must be followed, but most clinicians begin with assessment of mental status followed by the cranial nerves, motor system, reflexes, sensory system, coordination, and gait. Whether the examination is basic or comprehensive, it is essential that it be performed in an orderly and systematic fashion to avoid errors and serious omissions. Thus, the best way to learn and gain expertise in the examination is to choose one’s own approach and practice it frequently and do it in the same exact sequence each time. MENTAL STATUS EXAMINATION The bare minimum: During the interview, look for difficulties with communication and determine whether patient has recall and insight into recent and past events. The Folstein mini-mental status examination (MMSE) is a standardized screening examination of cognitive function that is extremely easy to administer and takes