week 2 neuro summary.pdf

2.1 intro and clinical presentation autoimmune disease MS autoimmune disease autoimmunity classifications 1. systemic :entire body is affected ex: lupus, RA, dematomyositis 2. organ specific : organ targeted by immune system based on receptor sensitivity ex: thyroid- hashimoto or graves type 1 dia...

2.1 intro and clinical presentation autoimmune disease MS autoimmune disease autoimmunity classifications 1. systemic :entire body is affected ex: lupus, RA, dematomyositis 2. organ specific : organ targeted by immune system based on receptor sensitivity ex: thyroid- hashimoto or graves type 1 diabetes-pancreas neuromuscular- myasthenia gravis myelin- MS and BS are target tissues pathophysiological differences GBS- PNS MS-CNS- brain and sc autoimmune pathophysiology autoimmunity: immune-mediated response of self antigens • immune system begins to attack body by generation of auto antibodies • normal circumstances: body has a natural autoimmunity and auto antibodies that exist as a way for the body to develop effective immune-related responses to pathogens. • exaggeration of autoimmune response occurs if pt becomes susceptible. etiology (combo) • genetics • lifestyle • environment • diet • stress • normal aging microbiome: influencer of local and systemic inflammatory responses -according to rosenbaum and colleagues genetic allele: shown to provide the predisposition regardless of trigger -according to atassie and kosali molecular mimicry once external stresses are added to a normal system, body's immune system responds by releasing inflammatory cytokines to mediate problem=causes activation of selfreactive lymphocytes= destruction of the target tissues. • immune system mistakes body for pathogenic molecules MS target tissue: myelin, oligodendrocytes and nerve cells of CNS *all autoimmune diseased originate from maladaptive factors in body but target tissue is diff -ppl w autoimmune disease are more prone to others if they dont mitigate prob why the fek do this gotta be so long clinical presentation myelin: meant to serve as insulator to nerves & aid in transmission of APs (bc of nodes of ranvier) forms a coating around nerve creating a tunnel so APs can • flow w no slowdown symptoms: begin w visual disturbances ex: diplopia and nystagmus presentations extensions of plaques • paresthesias • bradykinesia • fatigue • abnormal tone • tremors • ataxia • pain • dysarthria • generalized weakness forming damsons fingers around corpus callosum bc of break down of myelin and nervous tissue white plaques shown in T2-weighted MRI to diagnose MS -could be a distinguishing factor to rule in/out 4 phenotypes of MS 1. clinically isolated syndrome (CIS) isolated event of inflammatory demyelination that could progress to other forms if left unchecked • no other clinical features shown only MRI can show • can progress to 2. • ↓ relapsing remitting (most common) discrete attacks followed by near baseline recovery 3. • 4. secondary progressive worsening symptoms after relapse attack primary progressive • continuous worsening of symptoms from 1st onset • occurs w/out earlier relapses pts may have relapses attacks thru progression vo relapsing remitting for a little and then convert to secondary and get worse Summary Multiple Sclerosis manifests as an organ-specific autoimmune disease 4 Multiple Sclerosis Phenotypes 1. Clinically Isolated Syndrome 2. Relapsing Remitting 3. Secondary Progressive 4. Primary Progressive different presentations bc different lesions show up in new spots 2.2 medical management pharmacological interventions for acute exacerbation pharm management recommended for MS 1. methyprednisolone a corticosterioid drug w intention of decreasing inflammation w/in body and provides an immunosuppressive effect to decrease symptoms of attack administration: large doses intravenously for 3-5 days followed by a tapered oral administration many side effects! • 1. plasmapheresis -provided after acute exacerbations utilized when pts do not respond well to corticosteroid • treatment how its done healthcare professionals extract blood from pt and run it thru machine that separates red blood cells, white blood cells and plasma plasma portion is discarded and replaced w albumin • substitution fluid disease modifying agents (DMA) • attempt to decrease future disease attacks 4 themes of DMAs 1. need for early disease control to reduce i think we need to know these degree of disability 2. recognizing physical impairments that result from attacks and progression-one aspect of disability that needs to be mitigated 3. variable prognosis amongst pts 14 pharm DMAs approved by FDA 4. treatment adherence and any barriers to adherence-early one DMA is synthetic interferon drugs or beta interferons ex; avonex • slows down immune response and prevent activated T cells from crossing BBB kappas and colleagues say deep delay in disability after administration primary progressive MS ocrevus monoclonal antibody that works to deplete B cells from circulating side effects of all these drugs • flu like symptoms • injection site discomfort • rash • cardiac toxicity (severe cases) • anaphylaxis • hepatotoxicity • amenorrhea • infertility ALL ARE FOR RELAPSING FORMS OF MS spasticity does not moderate symptoms • can lead to lethargy and sleepiness 1. oral baclofen • in decreasing spasticity • consider: oral meds- no regulation of usually 1st to be prescribed and very effective initial administration is low w titration is based on results ???girl what effects on particular region of body pts that rely on spasticity to move can present w flaccidity instead bc of meds • 2. tizanidine decreases ability for fxnal intervention 3. dantrolene sodium 4. diazepam (valium) 5. intrathecal baclofen (ITB) • more invasive, less sedating • pts have to demonstrate lack of efficacy w oral spasmodic and/or adverse effects and no contraindications to surgery administration: small pump inserted w a catheter into intrathecal space of sc to make direct contact with CSF.. pump then able to be titrated thru pts skin if more/less meds needed • not local intervention • may decrease muscle tone 6. botox • used to assist w local spasticity • doesnt affect body systemically • lasts 3-4 months • PT needed to improve length and ex: for this pt they use botox and it helped w his extension proprioceptive aspects of muscle in hopes to decrease ROM deficits 7. tendon lengthening • last resort bc it comes w most challenges • mostly used for improved QoL pain 1. neuropathic pain: burning type or pins & needles • cymbalta® (selective serotonin and norepinephrine reuptake inhibitors (SSNRIs) • lyrica® (Pregabalin) to treat pain 2. paroxysmal pain: characterized by erythema of skin and warmth (flushed) w attacks of extreme pain • tegretol® (Carbamazepine) • elavil® (Amitriptyline) • dilantin® (Phenytoin) • valium® (Diazepam) • neurontin® (Gabapentin) 3. dysesthesias: noxious sensitivities to touch • elavil® (Amitriptyline) • tofranil® (Imipramine) • norpramin® (Desipramine) flashcards fatigue 1. symmetrel (amantadine) 2. provigil (modafinil) 3. fatigue management/exercise: better than meds tremor and nausea 1. Tremor a. antihistamines b. propranolol (Beta Blocker) c. Klonopin® (Clonazepam – Anti • deep brain stimulator may be surgically implanted to help manage side effects Anxiety) d. deep Brain Stimulators (DBS) 2. Nausea a. Antivert® (Meclizine) • can be used for general nausea b. Zofran® (ondansetron) • a,b prescribed c. Phenergan (promethazine) • c not very effective cognitive and emotional deficits 1. Cognitive Deficits a. cognitive Retraining b. aricept® (Donepezil) c. namenda® (Memantine) for alzheimer’s 2. Emotional Deficits/Anxiety a. prozac® (Fluoxetine) b. paxil® (Paroxetine) c. zoloft® (Sertraline) • treated w consultation of a speech and language pathologist • cognitive retaining protocols often used anti anxiety meds depression bowel and bladder deficits 1. neurogenic bladder: unable to control urine output due to NS deficits a. spastic : cause incontinence and abnormal emptying -anticholinergic medications 2. flaccid - crede maneuver: manual downward pressure on abdomen - intermittent self-cathetarization ~4-5x a day 3. both (dyssenergic) - alpha adrenergic blockers - anti-spasmodics • pts w MS often have difficulty w bowel impaction caused by constipation 4. bowel programs & dietary recommendations of increasing fiber intake are recommended to prevent stool impaction • pts should have an organized toileting routine to improve QoL and social QoL Summary Medical Management of the disease • Methylprednisolone • Plasmapheresis • Disease-Modifying Agents (DMAs) Medical Management of the symptoms • Pharmacological agents • Patient education 2.3 nutritional and alternative management-MS pharm interventions decrease adherence to medical protocols diet and nutrition • minimal dietary advice for ppl w MS swank diet 1990 -low saturated fat daily • no processed foods containing saturated fat or hydrogenated oils (cant exceed 15g per day & unsaturated fat at 20-50g/day) • eat as many fruits and veggies as desired • no red meat, including pork (for 1st year) then 3 ounces per week after that • skinless poultry and white fish permissible • no dark meat poultry and limited fatty fish • dairy products w/out butter • egg whites only • cod liver oil w other supplements • can eat whole grains and nuts • dairy (may increase risk)- further research needed • microbiome • controlled fat intake was associated w decreases in the inflammatory process -research showing the role of leaky gut or increased intestinal permeability to pathological material into the bloodstream • supporting fxns of gut and microbiome may help slow the diseases progress or symptomology the wahls protocol est. 2014 • emphasizes importance of diet and nutrition & management of MS terry wahls, MD- diagnosed w MS in 2000 -wheelchair bound due to progression & given chemo meds (didnt help) then went into research • institute of fxnal medicine (research of autoimmunity) • feed and support the mitochondria inclusion of -paleo diet diet similar to ^^.. 9 cups of veggies and colorful fruits daily • dairy free, gluten free, organic grass fed and wild caught went from wheel chair to riding 18 proteins and good fats: coconut, avocado and olive oil miles -exercise: stretching -electrical stimulation https://terrywahls.com/about/about-terry- -sleep, stress reduction and reduce toxic exposure wahls/ all of these factors improve QoL MS hope matthew embry- diagnosed in 1995 “living proof” documentary MS-direct • him and his fam provide free evidence for those w MS and its all rooted in scientific evidence • basis in diet, nutrition, exercise and other treatment like CCSVI vitamin and mineral supplementation epidemiology MS • further from equator more likely to get MS (those in northern hemisphere)-lack of sun sunshine: only natural contributor to vitamin D vitamin D: hormone not vitamin • decreased vitamin intake (sun or oral)= high risk of MS • some say diary puts you at high risk while others say it helps antioxidants used to decrease oxidative stress reaction of body polyunsaturated fatty acids: low fat diet w antioxidant and polyunsaturated fatty acids supplementation led to significantly lower C-reactive protein -decreases rate of relaps and associated fatigue swank and wahls-condone intake of cod liver oil as a source of polyunsaturated fatty acids vitamin A research says that increased uptake of vitamin A • vitamin D • polyunsaturated fatty acids (PUFAs) • vitamin B12 • alpha-lipoic acid improves cognition and counter disability vitamin B12 based on immunomodulatory effects and need to form myelin sheath • low B12 has been associated w RR MS alpha lipoid acid variabilities exist- more research needed alternative therapies and treatments • meditation: good adjuvant to traditional interventions • stem-cell therapy -research has shown to suppress MS for 4-5 yrs after stem cell tx in 70-80% of pts -procedures: good for young, ambulatory & have inflammatory or RR form of MS • chronic cerebrospinal venous insufficiency (CCSVI) -no significant difference summary Multiple alternative treatments - Diet/Nutrition - Vitamins and Supplementation Alternative Interventions - Meditation - Stem Cell Therapy -CCSVI all methods need further research 2.4 examination-MS like all pts a thorough examination is required for pts w MS test and measures: cognition and psychosocial fxn outcome measures for cognition 1. (MECFIMS) important to consider: *scheduling • -speed and working memory -learning and memory ask pt what type/time of day -executive fxn is best for them to avoid -visual spatial processing fatigue • tests and measures: sensation and pain sensation outcome measures • nottingham sensory assessment • monofilament testing -both not validated but still used for info of sensation • -word retrieval be cognizant of presentation and how long your evalv is visual analog scale pain • mcgill pain questionnaire • neuropathic pain scale • brief pain inventory VAS and these 3 pain scales used to quantify pain and sensation *WE NEED to know monofilament test, VAS and Mcgill pain provides 2 specific domains focused on cognitive processing via: fatigue is a BIG factor when working w MS pts • minimal examination of cognitive fxn in MS • more for speech and language patho and not PT 2. mini-mental state examination (MMSE) • comprised of a list of q’s and activities that pts fulfill w points devoted to each q’s comprised of things like: -spelling ‘world’ backwards -completing sentence w no ifs, ands or buts -drawing shapes that intersect • results varying levels of cognitive impairment psychosocial fxn 1. • MS quality of life scale pts may present w behavioral or depressive symptoms pseudobulbar affect emotional ability- occurs when an individuals are unable to control emotions w symptoms like laughing or crying uncontrollably presentations can also include: euphoria, depression, anxiety questionnaire tests and measures: neuro and msk neuro tests • CN integrity: CN 2,3,5,4,6,9,12 for visual, gag reflex (9), dysphasia (12) -vestibular cochlear nerve bc vestib symptoms • vision -for accommodation to light, blurred/double vision, saccades and nystagmus • modified ashworth scales: tonal abnormalities • DTR: babinski reflex • vestibular screen; vestibular deficits msk tests • ROM • strength: MMT or dynamometry -may not be telling bc they can score well on MMT but have weakness during fxnal activities test and measures: fatigue and temperature fatigue • modified fatigue impact scale (MFIS): used to measure how fatigue impacts cognitive, psychological and motor abilities in pts • fatigue scale for motor and cognitive fxns • visual analog scale temperature: pts have sensitivity to heat • uhthoffs phenomenon: 60-80% of pts- increases in core body temp can trigger symptoms to worsen -disorder thought to occur due to decreases in conduction velocity of neuronal circuitry related to temp important: facilities of exercise or aquatic environment have to be a good temp so pts dont get too hot -cold can exacerbate symptoms • • pseudoexacerbation symptoms are transient and last less than 24 hrs measurement w thermometer recommended in cases where pseudo-exacerbation and exacerbation occur test and measures: balance outcome measures • clinical test for sensory interaction and balance (CTSIB or M-CTSIB) • berg balance score (BBS) • tinetti POMA • BESTest require testing to provide idea of fxn -helps get idea of fall risk in some outcome measures no outcome measures specific to MS • test and measures: mobility gait and mobility • time up and go • temporal gait parameters • 10MWT • 6 min walk • dynamic gait index (DGI) • time 25 foot walk: very useful specifically for pts w MS • MS walking scale (MSWS-12): self reported walking index- how much the individuals diagnosis has impacted walking ability t & m: general health and aerobic capacity general health • health status questionnaire (SF-36): for ALL pts-info on general health -clinicians have difficult time distinguishing moderate and severe forms of MS w this aerobic capacity • BORG rating and perceived exertion (RPE) • dyspnea scale ❌ t & m: MS-specific expanded disability status scale (EDSS): gold standard in MS • research graded based on 7 systems: pyramidal, cerebellar, brainstem, sensory, bowel and bladder, visual and mental -use 1/2 point scale- 0=no impairement to 10=death -ambulation focused on as primary indicator of disability MS quality of life-54 (MS-QOL 54): combine w SF-35 for MS • -items ranked separately w subscales related to physical fxn: physical and emotional role limitations, pain, emotional, well being, energy, health perceptions, social fxn, cognitive fxn, health distress, QoL and sexual fxn MS QOL inventory (MSQLI): similar to ^^ • goals come up diagnosis, prognosis then establish goals • goals are specifically impacting disease itself • encompass ABCDEF (what is this again??)- bc of ‘f’ we can write goals related to fxn can write goals for improving WB and • alignment • meaningful goals for our pts • gait and transferability- more impactful for those in early stages impacts of disease • dont write goals specific to decreasing relapses, etc • QoL outcome measure goals body fxns/structures or impairment specific • ROM • pain • dont write goals for decreasing spasticity activity based/fxnal goals • should be emphasized • include objective data: asses quality of motor fxn Summary Same general examination procedures MS-specific nuances Goals specific to Activity 2.5 Rehabilitation Management - MS Intervention Types Preventative • minimizing complications • delaying exacerbation (good prognosis of baseline (later, severe stages) AD after exacerbation) • - All to help w/ ADL • neural plasticity • recovery of mvmt • task modification • - secondary prevention - ex: nutritionist Maintenance Restorative Compensatory decrease disability • education (pt/ caregiver) • assistive services • not covered by insurance - tertiary prevention Early Stage Interventions/Impairments Relapsing Remitting - will not show limitations • can affect instrumental ADLs, like social aspects compensatory strategies Preventative/Restorative Intervention • CV exercise • stretching • strengthening • education on energy conservation - know when overdoing things • environmental modification middle stages compensatory strategies Preventative/Restorative • mod independence bc mobility • using AD • consultations • psychological support • energy conservation activities - modify their sport late stages compensatory (improves QOL of pt/caregiver) Prevention WC cushion • • improve posture • education on bed mob • positioning to avoid contractures/atrophy pressure relieving AFOs/PRAFOs • - decreases integumentary compromise • lifting techniques Intervention for sensation Compensatory Restorative • proprioceptive loading through jts • weights w. resistance to improve body awareness • • • feet home environment - rugs moved sensory brushing/pharmacological - heightened sensitivity at soles of vision - contrast/lighting to prevent falls in environment - bright colored tape • eyepatch - diplopia do skin checks bc can lead to compounding integumentary dysfxn interventions for pain • pain directly from MS Lhermitte’s sign - PT can’t directly impact • - pharmacological agents/acupuncture/meditation • • pain due to MS symptoms use soft cervical collar for systemic body pain - pts will feel shocking pain if flex neck - ex: tight muscles/malaligned jts - postural reeducation - use swiss ball - stretching - improve flex, jt pain - aquatic therapy - calming - TENS • pain following medication • pain independent of MS - important to time therapy - referral interventions for exercise * exercise does not increase symptoms for people with MS usually* • schedule & dosage important - avoid overheating or exacerbation • current relapsing episode - no exercise until remission • vitals - RPE, HR, BP • stop when reach peak HR, dizziness, lightheadedness, or significant increase/decrease BP • maintain diary to see sleep, how costly ADLs are distributed practice best, 3-5x a week alt days w. 60-85% HR peak per session • recumbent bike • water aerobics • treadmills • VR/gaming Interventions for strength • progressive resistance bands • weight training • circuit training • WEIGHTED VEST: activity based training • closed chain exercises interventions for bowel and bladder control • voiding times for improved QOL • pelvic floor exercises interventions for flexibility • • HEP manual over pressure - good for spasticity - hold in end range for 30-60 seconds daily • splinting spasticity - Estim for strengthening of pelvic floor - dont stretch too much bc can make worse - weather can make worse: heat packs help - proprioceptive feedback: WB - Coordination & Balance: see ataxia/postural instability • WB activities for trunk stab - reduces unintended mvmts • PNF for coordination/stab - chop/lift/isotonic/reversal of antagonist/rhythmic stab - I I / dont do patterns emphasizing mvmts and not m stability, can make it worse 1 - - Interventions for gait: decreased balance, coordination, strength • fxnal gait in all directions • gait overground w/ assistance if can • more assistanceL bodyweight supported treadmill Orthotics/AD • • compensatory avoid bracing until really need to encourage muscles to do work - AFOs: help w/ DF in swing phase, decreased genu recurvatum during stance, decrease PF spasticity • later use power chair for energy conservation & participation in society summary combination of interventions • preventative • restorative • compensatory • maintenance interventions specific to symptoms and activity goal