HSE320 Exercise, Health and Disease PDF

6/17/2019 HSE320 Exercise, Health and Disease Neurological, Neuromuscular Disorders Part A: Pain, Peripheral...

6/17/2019 HSE320 Exercise, Health and Disease Neurological, Neuromuscular Disorders Part A: Pain, Peripheral Muscular & Neurological Disorders Ms Niamh Mundell, AEP Learning Objectives On completion of this presentation, you should be able to:  Define pain  Distinguish neurological vs neuromuscular disorders ‐ Peripheral muscular and neurological disorders ‐ Disorders involving the spinal cord ‐ Disorders involving the basal ganglia ‐ Cerebellar and cortical disorders Neurological / Neuromuscular Myopathies A problem in the muscles Neuropathies A problem in the neural structures 1  6/17/2019 Mechanisms of Pain Pain is the response of a nerve and can be linked with: Pressure: structures containing nerve endings Nerve root Trunk Branches Nerve endings Tension: on structures containing nerve endings sensitive to deformation Stretch Strain Prolonged distortion of body alignment Sensory disturbance: Excellent aid in determining level of lesion Pain can be: LOCALISED WIDESPREAD: generalised or referred Pain Several million bare sensory nerve endings through all tissues & organs of the body Respond to a noxious stimuli Endorphins – reduce our perception of pain Bradykinin  most potent pain producing chemical known  initiates release of inflammatory chemicals  binds to pain receptors causing ongoing firing Somatic pain  Skin, muscles, joints  Superficial (sharp) or deep (burning, aching) Visceral pain  Organs of thorax & abdominal cavity  Dull ache, burning, gnawing  Because inputs follow the same pathways as somatic pain, may cause pain to be perceived as somatic Painful stimuli such as intense heat activate the peripheral terminals of nociceptors. Pain perceptions influenced by: Age Gender Fatigue Memory Pain occurs in the brain! Stucky C L et al. PNAS 2001;98:11845-11846 2  6/17/2019 Peripheral Muscular & Neurological Disorders Muscular dystrophies  Duchenne Muscular dystrophy Peripheral Neuropathies  Carpal tunnel syndrome Amyotrophic lateral sclerosis  Lou Gehrig’s disease Muscular Dystrophy Muscular dystrophy – group of inherited muscle‐destroying diseases where muscles enlarge due to fat and connective tissue deposits, but muscle fibers atrophy Progresses from the extremities upward, and victims die of respiratory failure in their 20s There is no cure, but myoblast transfer therapy shows promise Muscular Dystrophy Duchenne muscular dystrophy (DMD)  Most common & serious form  Inherited, sex‐linked disease carried by females and expressed in males (1/3500)  Diagnosed between the ages of 2‐7  Victims become clumsy and fall frequently as their muscles fail  Dysfunction of a cytoplasmic protein that effects the integrity of the sarcolemma – results in excess Ca2+ into contractile fibres = breakdown Copyright © 2006 Pearson Education, Inc., publishing as Benjamin Cummings 3  6/17/2019 Muscular Dystrophy Exercise prescription Consideration Recommendation Ambulation difficulties Cycling or arm ergometers (10+, most children are wheelchair bound) Using equipment that has appropriate support relative to the individuals functional ability However, if ambulation is possible, exercise accordingly Scoliosis Strengthening & stretching program for posture Associated cardiomyopathy Must be aware of cardiac involvement prior to exercise program and adjust & monitor exercise accordingly Cognitive developmental delays Expectations of cognitive capacity for the age of child Contractures May need to be creative with equipment use Strength training may start at ~25% 1RM with low reps (8 – 10), progressing slowly up to 50 – 75% 1RM and multiple sets Low bone density Be wary of non-contact sports Cataracts Poor eye-hand co-ordination Side effects of drug therapy - > fat mass, Weight Mx exercise < bone density, hyperthermia (renal failure) Monitor urine & avoid strenuous exercise in heat Daytime somnolence - compliance Short term goals need to be achievable and sessions need to be fun and enjoyable Peripheral Neuropathies  Slowing or complete interruption of conduction along a peripheral nerve pathway  Can effect: one nerve (mononeuropathy), multiple nerves (multiple mononeuropathies) or be a systemic disorder (polyneuropathies)  Carpal tunnel syndrome – best known mononeuropathy Entrapment of the median nerve at the carpal tunnel 4  6/17/2019 Mononeuropathies  Address mechanism of entrapment. Examples include stretching agonist strengthening antagonist load Mx body weight technique Diabetic Neuropathies  Vascular damage blood flow impedance and death of nerve tissue  Loss of sensation Other Causes  Trauma  Systemic disease  Infection  Autoimmune disorders  Genetic 5  6/17/2019 Amyotrophic lateral sclerosis Lou Gehrig’s disease Progressive death of α‐motoneurons (innervate skeletal muscle) leading to a loss of voluntary muscle control Ultimately paralysis including muscle involved in breathing 1 in 15,000 in the US Affects men more frequently than women Exercise is indicated to alleviate symptoms Amyotrophic lateral sclerosis Exercise prescription Maintain fitness and independence – CV health, fatigue & depression – Low impact aerobic exercise (30 – 50% peak work rate, daily) ROM & stretching – To assist with spasticity & contractures (1 – 2 sessions per day) Strengthening – Major muscle groups, light weight, 1 set, 8 – 12 reps Mobility & balance – Maintain independence Focus of exercise needs to be ADL’s & functional capacity without fatigue. QUICK QUIZ? What is the difference between visceral and somatic pain True or False? Duchenne Muscular Dystrophy presents more commonly in females Which motor neurons are progressively lost with ALS? Give an example of a peripheral neurological disorder? What are the symptoms of Duchenne Muscular Dystrophy? What is the main focus of exercise prescription for ALS? 6  6/17/2019 HSE320 Exercise, Health and Disease Neurological, Neuromuscular Disorders Part B: Disorders of the Spinal cord, MS, PD and Huntington's Chorea Ms Niamh Mundell, AEP Spasticity Spinal cord injury Multiple Sclerosis Stroke Parkinson’s Disease Cerebral palsy Brain injury Spasticity = velocity dependent resistance to stretch Contracture = fixed resistance at joint capsule Spinal cord injury Spinal cord shock: temporary loss of spinal reflex activity below the level of the injury, impaired sympathetic outflow, may cause hypotension/ bradycardia – Cx trauma & paralysis inferior to the site of the lesion, yet no # or dislocation is evident – Osteoarthritis: encroachment into the vertebral canal & swelling may exert pressure on spinal nerve roots – Sensory & motor Sx in the area of distribution may be present 7  6/17/2019 Spinal cord injury  C1‐C3: no function below head level; a ventilator is required  C4‐C5: respiration occurs; quadriplegic  C6‐C8: loss of hand & variable movement of the upper limb; may be able to self‐feed or propel a wheelchair  T1‐T9: paraplegic & the amount of trunk control depends on the level of the lesion  T10‐L1: some thigh muscle function which may allow walking with long leg braces  L2‐L3: most leg function retained, short leg braces may be required for walking Spinal cord injury Exercise prescription Consideration Recommendation Osteoporosis in LL Possible contractures – consider manual stretching intervention Pulmonary limitations with VO2 peak Often dictated by exercise tolerance, taking into account cardiac monitoring. Allow for rest periods dependent on total active muscle mass between efforts. Can use RPE as a guide. Spastic v flaccid paralysis Spastic paralyzed muscles respond to electrical stimulation for therapeutic purposes Flaccid paralysed muscles do not. Also need to consider a lack of venous muscle pump – consider body position Insensate areas Pressure ulceration Bladder & bowel control Empty bowel & bladder prior to exercise, particularly hydrotherapy Hypo/hypertension Monitor BP Thermal regulation Monitor environmental conditions, this includes heat & cold Tetraplegia Must always be supervised Depression Compliance Multiple sclerosis Demyelinating disease Autoimmune disease (attacks myelin proteins) that gradually destroys the myelin at scattered sites (segmental) within the white matter of the CNS – primary demyelination (axonal preservation) Myelin is reduced to non‐functional hardened lesions called scleroses Shunting & short‐circuiting (reduction in conduction velocity) of the electrical currents – slowing & eventual cessation of impulse conduction Spontaneous increase in Na+ channels in the demyelinated fibres may account for the cycles of relapse & remission However, subsequent axonal loss has also been found to contribute to the progression of the disorder Affects mostly young adults Symptoms: visual disturbance, NM control (ultimately paralysis), speech disturbances, urinary incontinence 8  6/17/2019 Multiple Sclerosis Exercise prescription Consideration Recommendation Incontinence Voiding before exercise Balance problems Consider weight bearing status and balance/ambulation aids Sensory loss to the lower extremities Often need to use straps or braces when using for example a recumbent bike Thermoregulation Hydration & neutral thermal environment CV response to exercise Monitor HR & BP 60 – 85% peak HR 30 min sessions 3 x p/wk LL muscle weakness & premature fatigue Do not do strength & aerobic fitness on the same day Functional, large muscle group strength Depression Compliance ROM/flexibility Daily 9  6/17/2019 Disorders involving the basal ganglia Parkinson’s disease Huntington’s disease Parkinson’s disease  Located in the midbrain is a pigmented nuclei – substantia nigra (component of basal nuclei – influences motor activity)  Precursor for the release of neurotransmitter – dopamine  Degeneration of these dopamine‐releasing neurons is the ultimate cause of Parkinson’s disease  Symptoms do not occur until > 80% of loss of dopaminergic cells  Idiopathic neurodegenerative disorder  Symptoms include resting tremor, slow movements, rigidity, gait & postural abnormalities  Dopamine effect – not entirely clear & current hypotheses and debated Exercise and Parkinson’s disease Exercise may have little effect on the symptoms directly associated with the disease but have some benefits to indirect effects such as MSk & CP changes. Exercise intensity and duration should be increased, but very slow progression (every 4 – 6 weeks). Dyskinesia & dystonia can aggravate degenerative joint disease. 10  6/17/2019 Parkinson’s disease Exercise prescription Consideration Recommendation Balance is compromised Where ambulation is possible, must be supervised, particularly if using a treadmill, client should use a safety harness. 4 – 6 sessions per day of short, walking bouts Motor planning and motor memory Repeated cues Aerobic exercise HR response may change from day to day for the same output levels 60 – 80% peak HR 3 days p/wk Up to 60 mins – if tolerated (often not completed ambulating) Strength Light weights 8 – 12 reps (1 set) 3 days p/wk Flexibility 1 – 3 sessions p/wk Functional capacity All exercise should aim to maintain ADL repertoire and capacity Facial expression Often a mask-like presentation thus difficult to gauge reaction to exercise Time of day Try to be consistent/routine with exercise protocols Huntington’s disease Rare, hereditary, neurodegenerative disorder Atrophy of the caudate nucleus (neural structure of the basal ganglia) Chorea (best known motor feature): – Irregular restlessness – Dance‐like gait – Clumsiness & slurry speech Non‐motor features include: – Depression – Irritability – Dementia Later stages of the disease exhibit symptoms similar to Parkinson’s disease Exercise considerations similar to that of Parkinson’s disease QUICK QUIZ? What is spinal cord shock? Summarise the functional consequences of a spinal cord lesion at cervical, thoracic and lumbar regions? What is autonomic dysreflexia and how can you monitor for this? What are the symptoms of MS? True or false: an increase in Na+ channels in the demyelinated fibres may account for the cycles of relapse & remission in MS? What are some precautions with exercise prescription for MS? What are some of the exercise prescription guidelines for PD? 11  6/17/2019 HSE320 Exercise, Health and Disease Neurological, Neuromuscular Disorders Part C: Stroke, CP, ABI Ms Niamh Mundell, AEP Cerebrovascular Accident (CVA)  Stroke is Australia’s second greatest killer after coronary heart disease and a leading cause of disability.  In 2009, Australians will suffer around 60,000 new and recurrent strokes (one stroke every 10 minutes).  One in five people having a first‐ever stroke die within one month and one in three die within a year.  The number of strokes will increase each year due to the ageing population. Epidemiology  In the next 10 years more than half a million people will suffer a stroke.  Stroke kills more women than breast cancer.  About 88% of stroke survivors live at home and most have a disability.  Close to 20% of all strokes occur to people under 55 years old.  Strokes cost Australia an estimated $2.14 billion a year. 12  6/17/2019 CVA Risk Factors Risk Factors: – Hypertension – Diabetes – Smoking – Alcoholism – CAD Other Factors: – Obesity – Platelet hyperaggregability – Elevated lipid levels Stroke Cerebral Vascular Accident (CVA) Vascular insufficiency or ischemia Results in neurological impairment dependent on area of the brain affected. Pathophysiology (two main types):  Ischemic Stroke  Haemorrhagic Stroke Diagnosis – CT Scan or MRI 13  6/17/2019 FACE  Check their face. Has their mouth drooped? ARMS  Can they lift both arms? SPEECH  Is their speech slurred? Do they understand you? TIME  Time is critical. If you see any of these signs, call 000 now! National Stroke Foundation www.strokefoundation.com.au Transient Ischemic Attacks (TIA) Caused by the changes in the blood supply to a particular area of the brain, resulting in brief neurologic dysfunction that persists, by definition, for less than 24 hours; if symptoms persist then it is categorized as a stroke. Cerebrovascular Accident Exercise prescription  Depending on severity and deficits, may need specialized care to perform exercise in these patients.  Must watch for issues such as weakness, poor balance, and cognitive and behavioral abnormalities that may affect exercise performance.  Can respond to both aerobic and resistance training, but note that most patients are quite deconditioned. 14  6/17/2019 Cerebrovascular Accident Exercise prescription  Highly individualized programs.  Hypertension and excessive blood pressure responses are of concern.  3‐5 days per week at lower intensities (40%‐50% of peak).  Since often patients are very deconditioned, duration should be limited during initial stages and progressed accordingly.  Hypertonia and spasticity are important considerations.  Resistance training is appropriate in select individuals. Cerebrovascular Accident Exercise prescription Reduce risk factors for subsequent strokes by: – Reduce hypertension – Enhance glucose regulation – Improve lipid profile – Reduce body fat Other Considerations ECG monitoring (stroke patients are high risk for CHD). Comorbidities may require modification of the exercise mode. Injury risk due to impaired sensation. 15  6/17/2019 Cerebral palsy  Non‐progressive lesion on the brain, which occurs before, at, or soon after birth that interferes with the normal development of the brain.  Permanent disorders affecting the development of movement and posture, causing activity limitation.  Often accompanied by disturbances of sensation, perception, cognition, communication, behaviour, epilepsy, and secondary musculoskeletal problems. About Cerebral palsy  There is no known cure for CP.  Medical intervention is limited to the treatment and prevention of complications arising from CP's effects.  In Australia, 1 in 400 babies are diagnosed with cerebral palsy.  Improvements in neonatal nursing have helped reduce the number of babies who develop cerebral palsy, but the survival of babies with very low birth weights has increased, and these babies are more likely to have cerebral palsy. Type of Cerebral palsy 16  6/17/2019 Comorbidities  Mental disadvantage (IQ < 50): 31%  Active seizures: 21%  Mental disadvantage (IQ < 50) and not walking: 20%  Blindness: 11% Johnson, Ann (2002). Developmental medicine and child neurology 44 (9): 633–40 Symptoms  All types of CP are characterized by abnormal muscle tone (i.e. slouching over while sitting), reflexes, motor development and coordination.  There can be joint and bone deformities and contractures (permanently fixed, tight muscles and joints).  The classical symptoms are spasticities, spasms, other involuntary movements (e.g. facial gestures), unsteady gait, problems with balance, and/or soft tissue findings consisting largely of decreased muscle mass. 17  6/17/2019 Symptoms  The effects of cerebral palsy fall on a continuum of motor dysfunction ranging from virtually unnoticeable to "clumsy" and awkward movements to such severe impairments that coordinated movements are almost impossible.  The full intellectual potential of a child born with CP will often not be known until the child starts school.  People with CP are more likely to have some type of learning disability.  Intellectual level among people with CP varies from genius to mentally retarded.  It is important to not underestimate a person with CP's capabilities and to give them every opportunity to learn. Secondary Conditions Seizures Epilepsy Speech (apraxia or dysarthria) or communication disorders Eating problems Sensory impairments Mental retardation Learning disabilities Behavioural disorders Cerebral palsy Exercise prescription Programs are designed to encourage the patient to build a strength base for improved gait and volitional movement, together with stretching programs to limit contractures. Many experts believe that life‐long physical therapy is crucial to maintain muscle tone, bone structure, and prevent dislocation of the joints. 18  6/17/2019 Cerebral palsy Exercise prescription Programs should focus on: – Muscular strength – Flexibility – Aerobic endurance Overall goal to improve health and increase daily functional activities. Progression should be gradual and increase at the individual’s own rate. Programs need to be adapted according to the nature of presentation. Benefits of Exercise for CP Improved sense of wellness Body image Lessening of the severity of symptoms Increase capacity to perform ADLs Athletes with CP Improve VO2peak Lowered ventilatory threshold Increased work rate at submaximal heart rates Increased range of motion Improved coordination and movement skill Increased muscular strength and endurance Skeletal muscle hypertrophy 19  6/17/2019 Other Considerations Straps may be necessary to keep hands and feet secure during arm or leg cycling. Medications may decrease aerobic capacity as well as attention span and motivation. Extra safety considerations and supervision due to poor balance and coordination. Exercise duration is more important than intensity. Acquired brain injury Post CVA or traumatic Primary insult – structural injury Secondary insults – eg. edema, ischemia, metabolic derangements in addition to primary injury – may increase extent of damage CVA – localised effect, ABI – diffuse brain injury & subsequent impairments Effect depends on neurological involvement & existing co‐morbidities Glasgow Coma Scale Acquired brain injury Exercise prescription Similar to that for CVA/Stroke Slow progression Strength & NM co‐ordination Multiple sets & med‐high reps May need to be creative Focus on functional outcomes 20  6/17/2019 QUICK QUIZ? True or False? Stroke kills more women than breast cancer. What is the difference between ischemic stroke and hemorrhagic stroke How can we reduce risk factors for subsequent stroke? What are the characteristics of cerebral palsy? Give some examples of secondary insults and their causes in ABI Summary  Pain is a neurological phenomenon  Distinguish neurological vs neuromuscular disorders ‐ Peripheral muscular and neurological disorders: Muscular dystrophies, Peripheral Neuropathies, Amyotrophic lateral sclerosis ‐ Spinal cord injury (SCI) ‐ Multiple Sclerosis ‐ Parkinson’s Disease, Huntington’s ‐ Stroke (CVA) ‐ Cerebral Palsy ‐ Acquired Brain Injury 21