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NM I &II - Coggle Diagram
NM I &II
Parkinsons
4 cardinal signs
- resting tremor (pill roll)
- postural instability
- bradykinesia
- Rigidity
Postural instability
- increases incidence of falling
- Due to ineffective sensory processing as there are deficits in proprioception and kinesthetic awareness. this is why they are overdependent on vision for balance
- poor anticipatory balance reactions
- mix LE balance strategies
Bradykinesia
- can be akinetic too
- worse with complex movement like sequential tasks or transitional movement
- can delay activation of movement
- can look like strength deficits but is actually due to lack of Dopamine
Rigidity
- increased resistance to passive movement 2 types
- Lead pipe - increased resistance in entire range in both directions
- cogwheel rigidity- rachet like stop start , its like lead pipe mixed with tremor
- Rigidity increases energy perception and fatigue
PD gait changes
-
Fenistation Gait - Rapid small steps done to keep COG in between feet with the trunk leaning forward. can appear to be running
-
Decreased arm swing, stooped posture with forward flexion
Freezing of gait
- episode where it feels like their feet are glued to the ground
- most often occurs when walking through doorway, turning 360, walking in narrow spaces, stepping from one surface to another, stressful situations;
Other MOTOR signs
- hypophonia (soft speech)
- facial masking
- micrographia
- dysphagia
- dystonia - sometimes painful spasm or twitching at the early stage of a movement
- dyskinesia - involuntary erratic movement, non painful and a result of the medication
Non motor / cognitive signs of PD
- slowing of thought
- trouble with shifting attention
- orthostatic hypotension
- bladder and genital issues
PD classification of disability
- 0- no signs of disease
- 1- unilateral symptoms only
- 2- bilateral symptoms without balance impairment
- 2.5 Mild bilateral disease with recovery on pull test
- 3 Balance impairment
- 4- severe disability but still able to walk or stand unassisted
- 5- needing a wheelchair or bedridden unless unassisted
Objective measures
- MDS- UPDRS measures progression of motor symptoms. Used to ID between tremor dominant and postural / gait difficulty
PD plus syndromes
- progressive supranuclear palsy
- Multiple systems atrophy
- dementia with Lewy bodies
Progressive supranuclear palsy
- develops later
- symmetric axial oriented and akinetic
- levodopa resistant
- EARLY postural instability
- Supranuclear gaze palsy
- more severe dysphagia
Multiple systems atrophy
- rapid progression of symptoms
- Dysautonomia
- Urinary incontinence and ED
- PISA syndrome with posture
- REM disorder where they act out their dream
- 2 types parkinsonian and cerebellar
Exam in PD
For hypokinesia and movement system
- arrest ongoing movement in functional tests
- delayed or absent timing of postural adjustments
- slowness in reciprocal movement
- loss of balance in posterior early
- loss of balance in termination of movement
- unable to regulate step length
other specific OM
- Mini best
- 9 hole peg
- MOCA
- MDS- UPDRS
- FOG questionnaire
- Parkinson's fatigue scale
- Parkinson's disease questionnaire
TUG cognitive
- complete tug while counting backwards by 3s from a number between 20-100
- OVER 15s is predictive of a fall
Treatment options of PD
- CPG is for H & Y levels 1-3
SHOULD DO Aerobic exercise for PD
- mod intensity is 60-75% HRm
- High intensity is 75*85% HRm
- optimal dosing not ID but 30-40min for 3 days a week is good
- studies are done on treadmill of bike, but can be done on anything
- should be gradually progressed if sedentary before
SHOULD do progressive Resistance
- 1-2 days a week for 30-60min while applying 80% of 1RM, 40% if power
- can follow regular guidlines
- 1-3 min of rest
- think of impairments in posture
SHOULD do Balance training
- use minibest as primary OM
- use perturbation, wt shift
- 2-3 times per week for 5-10w with tx of 15-30 min
- needs to be high intensity so at home work is less effective
Flexibility
- can recommend outside programs like yoga**
External cues
- we should implement external cues for FOG and gait
-
Motor fluxuations of PD
- will have on off periods, its important that we see both
ALS
- rapidly progressive neurodegenerative disease characterized by the degeneration and eventual death of UMN and LMN causing weakness in limbs, respiratory, bulbar musculature
- clinical diagnosis through El escorial criteria
Spinal onset (more common)
- fasciculations, atrophy, muscle weakness
- damage to CTS
- presents in musculature and progresses proximally
Bulbar onset
- faster progression
- changes in speech
- damage to brainstem
- difficulty swallowing
- involuntary tongue fasciculations
- vocal cord spasm
ALS with FTD
- 20% develop
- will have changes in behavior (disinhibition, lack of judgment, apathy)
- difficulty with ethe xpression of language
- deficits in executive function
Most commonly reported symptoms
- fatigue is 90%
- muscle stiffness 84%
- muscle cramps 74%
PT goals
- Main Optimize function, mobility and independence
- Secondary- assess equipment needs, reduce secondary complications,m address body function impairments
Exam
- know time of onset
- know the location of onset
- get idea of life and living situation
- know what they want out of PT
- Movement analysis Force production deficit
- look at skin
- check cognition and respiratory
- spasticity
- pain
- Look at muscle wasting
Objective measures
- Gait - 10mwt , 6MWT
- balance- berg, TUG, function in sitting
- QOL- Als specific QOL scale
- PSFS
Intervention by stage
Stage 1
- mild to moderate weakness in specific muscle groups
- difficulty withe ADLs and mobility toward the later part of this stage
Stage 1 ALS interventions
remediation
- Strengthening w proper dose
- AROM and Flexibility for contracture
- fall prevention strategy
compensation
- Assess need for ADs
- energy conservation strategies
- disease education
Aerobic dose
- MODERATE intensity at 50-65% HRR without inducing excess fatigue
- rest periods recommended
Resistance exercise
- Mild to mod ONLY for muscles that can move against gravity (3/5 MMT) in early stages
- emphasize concentric rather than eccentric
ALS stage 2
- increased fatigue and difficulty with ADLs
- wheelchairs for long distances
- severe muscle weakness
- pain
ALS stage 2 interventions
compensation
- support muscles through bracing and AD
- wheelchair assessments
- caregiver education
prevention
- impairment
- fall prevention
- pressure relief
ALS stage 3
- dependent for most mobility and ADL and transfers
- severe weakness
- respiratory compromise
- pain
ALS stage 3 interventions
- PROM
- skin care
- pulmonary hygiene
- education for caregivers
Stroke
Ischemic stroke
ACA
Signs of ACA
- Contralateral hemiplegia with LE more involved
- Profound Albula (lack of willpower)
- Apraxia (speech and motor difficulty)
- urinary incontinence
- Flat affect
- perseveration
MCA
Signs of MCA
- contralateral hemiplegia (more face and UE)
- CL hemianesthesia
- homonymous hemianopia (lack of vision on CL)
Right MCA
- Left neglect
- impulsiveness
- Decreased spatial awareness
L MCA
- Aphasia
- Apraxia
- Compulsiveness
PCA
Signs of PCA
- thalamic sensation ( abnormal sensation to pain, temp, touch , proprioception)
- exaggerated sensation
- Vertical gaze palsy
- homonymous hemianopia
- Cortical blindness
Basilar stroke
Signs of basilar stroke
- B sensory loss
- Locked in syndrome
- unilateral CN sensory and motor loss
- vertigo
- vomiting
- nausea
Cerebellar strokes
Signs of cerebellar
- if unilateral they will affect the same side of the body
- Ataxia
- vertigo
- nausea / vomiting
- tremors
- coordination issues
Superior cerebella stroke
- severe ipsilateral ataxia
- N / V
- dysarthria
- CL loss of pain and temp
- Ipsilateral UE dysmetria
Anterior inferior cerebellar art
- Ataxia
- ipsilateral deafness
- facial weakness
- vertigo
- N / V
- CL loss of pain and temp
posterior Inferior cerebellar artery
- Wallenberg syndrome
- ipsilateral ataxia
- Ptosis
- ipsilateral facial sensory impairment
- CL sensory impairment in trunk and extremities
Wallenberg syndrome signs
- difficulty swallowing
- hoarseness
- dizziness
- nystagmus
- balance
- lack of pain
Hemorrhagic strokes
Epidural
- meningeal arterial bleed following head trauma or skull fracture
Subdural
- damage to the bridging veins, more common in the elderly and usually due to head trauma
- mild HA and change in mental status
Subarachnoid hemorrhage
- arterial bleed
- Thunderclap headache
- usually due to aneurysm and AVM
- 90% are berry
Intracerebral ICH
- arterial bleed
- usually due to vascular disease
-
Myasthenia Gravis
- chronic peripheral autoimmune disorder of the NMJ
- they will have a slow onset of symptoms
Aerobic
- can do 3 sets of 10-12 min of biking or 2-3min on and 2 min off
Resistance
-2 sets
monitor their fatigue, many will know their limits
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