Neuro Notes Clin(BookFi.org)

["295 Guillain-Barr\u00e9 Syndrome Description\/Overview Guillain-Barr\u00e9 Syndrome (GBS) is an acute inflammatory disease that results in demyelination and\/or axonal degeneration in peripheral nerves, spinal sensory and motor nerve roots, and at times in cranial nerves. Criteria used in the diagnosis of GBS include: \u25a0 A history of flu-like symptoms preceding the GBS symptoms \u25a0 Progressive motor weakness in more than one limb \u25a0 Symmetric, bilateral pattern of weakness \u25a0 Cranial nerve involvement \u25a0 Diminished or absent deep tendon reflexes \u25a0 Progression of symptoms stabilizes after 2 to 4 weeks Medical Red Flags All assessment and intervention should cease; medical attention should be obtained. Deep Vein Thrombosis Symptoms Possible Causes Management \u2022 Swelling, heat and \u2022 Due to immobilization, \u2022 Cease treatment and erythema in the thrombus may form seek immediate involved area in deep veins in legs medical attention and\/or arms \u2022 Positive Homans\u2019 sign \u2022 Avoid any exercise of the lower extremities POLY-PNS","POLY-PNS Autonomic Disturbances Symptoms Possible Causes Management \u2022 Tachycardia \u2022 Dysfunction in \u2022 Cease treatment \u2022 Bradycardia parasympathetic and and seek immediate \u2022 Paroxysmal sympathetic systems medical attention hypertension \u2022 Anhidrosis or diaphoresis \u2022 Orthostatic hypotension Respiratory Distress May occur in first few weeks of disease Symptoms Possible Causes Management \u2022 Change in \u2022 Severe weakening of \u2022 Cease treatment and seek immediate cardiopulmonary respiratory muscles medical attention function including dyspnea and tachypnea Dysphagia Symptoms Possible Causes Management \u2022 Pain on swallowing \u2022 Decreased coordination \u2022 For aspiration, seek \u2022 Choking \u2022 Aspiration of swallowing muscles immediate medical \u2022 Airway obstruction \u2022 Pneumonia \u2022 Diminished swallow attention reflex \u2022 Administer the \u2022 Reduced lingual and Heimlich maneuver pharyngeal control or CPR, if warranted \u2022 Cranial nerve deficits \u2022 Speech-language feeding program 296","297 Precautions \u25a0 Overuse of painful muscles may result in prolonged recovery period or lack of recovery; frequent rest periods are recommended \u25a0 Overstretching can occur due to the denervation and weakened muscle Physical Therapy Examination History Refer to Tab 2 for full history. Include: \u25a0 Date of onset \u25a0 Description of progression of symptoms Tests and Measures Aerobic Capacity\/Endurance \u25a0 Assess BP, RR, and HR at rest and during and after exercise \u25a0 Use the Borg Rating of Perceived Exertion (Refer to Tab 2) Potential findings \u25a0 The respiratory status may be impaired in the initial stages of GBS \u25a0 Initially endurance is poor and overexertion should be avoided Assistive and Adaptive Devices Assessment \u25a0 Assess the need for assistive or adaptive devices and equipment for functional activities Findings \u25a0 A WC is usually required during the initial few months; selection should consider avoidance of muscle fatigue, existing strength, need for positioning, and ease of maneuvering in patient\u2019s home\/work environment Circulation Potential findings \u25a0 Decreased cardiac output and cardiac arrhythmia \u25a0 Fluctuations in blood pressure between hypotension and hypertension POLY-PNS","POLY-PNS Cranial and Peripheral Nerve Integrity Assessment \u25a0 Assess cranial nerves (CN) (Refer to Tab 2) Potential findings \u25a0 CN involvement may cause weakness of the ocular muscles and reflex responses (CN III, VI, and X), facial (CN VII), and oropharyngeal (CN IX and XII) muscles \u25a0 Resultant dysphagia, dysarthria, ophthalmoparesis, and ptosis may occur Assess peripheral nerves for sharp\/dull discrimination and light touch. Potential findings \u25a0 Deficits in sharp\/dull discrimination and light touch are often long standing Environmental, Home, and Work Barriers (Refer to Tab 2) Gait, Locomotion, and Balance Balance assessment using (Refer to Tab 2) \u25a0 Romberg and Timed Up and Go \u25a0 Berg Balance Scale \u25a0 Performance-Oriented Mobility Assessment Gait and locomotion assessment \u25a0 Observational Gait Analysis (Refer to Tab 2) Potential findings \u25a0 Gait and balance will be affected by pain, diminished endurance, and muscular weakness \u25a0 Common findings include a drop foot and diminished heel strike Motor Function Assessment \u25a0 Use the Rivermead Mobility Index (refer to Tab 2) 298","299 Muscle Performance Considerations \u25a0 Caution should be taken to avoid overexertion so manual muscle test- ing should be done over several sessions \u25a0 Avoid substitutions for weakened muscles Assessment \u25a0 Manual muscle testing of individual muscles (as opposed to testing muscle groups) should be performed for monitoring progression \u25a0 Facial and respiratory muscles should be tested \u25a0 Use dynamometry to improve sensitivity to change in strength over time Potential findings \u25a0 Muscular weakness generally proceeds in a symmetric manner from proximal to distal, first in the lower, then the upper limbs \u25a0 Facial and respiratory muscles are often involved Orthotic, Protective, and Supportive Devices Considerations \u25a0 The need for devices is usually short-term so consideration should be given to cost \u25a0 An ankle-foot orthotic is often required due to residual weakness of the anterior tibialis and intrinsic muscles of the foot \u25a0 Resting splints may be needed to prevent contractures of the hands and ankles Assessment Assess the need for: \u25a0 Orthotic devices \u25a0 Positioning devices to reduce or eliminate pressure (e.g., specialty pressure reducing mattresses, cushions, multipodus boots, etc.) \u25a0 Walkers, crutches, and canes POLY-PNS","POLY-PNS Pain Assessment \u25a0 Universal Pain Assessment Tool (Refer to Tab 2) \u25a0 Note areas and type of pain on the Ransford Pain Drawing (Refer to Tab 2) Potential findings \u25a0 Pain, which may be severe, often occurs in the back and legs \u25a0 Pain often worsens at night \u25a0 Pain may be described as feelings of dysesthesia, such as burning, tingling or shock-like Reflex Integrity Assessment \u25a0 Assess deep tendon reflexes Potential findings \u25a0 Deep tendon reflexes are diminished or absent in the early stages of the illness Self-Care and Home Management Assessment \u25a0 Assess with the Functional Independence Measure (FIM) \u25a0 Administer the Katz Index of Activities of Daily Living (Refer to Tab 2) Sensory Integrity Assessment \u25a0 Establish sensory system functional status (somatosensory, vision, hearing) before completing cognitive\/perceptual testing \u25a0 Assess superficial (pain, temp, touch), deep (proprioception, vibration) and combined cortical sensations Potential findings \u25a0 Initially there is paresthesia or anesthesia beginning in the feet, although this may also occur in the hands \u25a0 Decreased vibratory and position sense may be present 300","301 Ventilation and Respiration Assessment Assess respiratory status including: \u25a0 Auscultation of lungs for breath sounds \u25a0 Pulse oximetry \u25a0 Signs of dyspnea and tachypnea \u25a0 Tidal volume and vital capacity with spirometry \u25a0 Strength of cough \u25a0 Ability to clear airway \u25a0 Chest expansion \u25a0 Use the Medical Research Council Dyspnea Scale during and after exercise (Tab 2) Potential findings \u25a0 Impaired respiratory muscle strength can result in a weak cough, decreased vital capacity, tidal volume, and oxygen saturation \u25a0 Aspiration may occur when there is cranial nerve involvement resulting in oromotor weakness Work, Community, and Leisure Assessment \u25a0 Assess mobility skills with WC, orthotics, and\/or assistive devices within the community and work environments Medications\/Treatment \u25a0 Plasmapheresis has been found to shorten the course of GBS and to lessen symptoms POLY-PNS","POLY-PNS Medications Indications Generic Name Brand Name Common Side Effects GBS symptoms IV immunoglo- Gammagard Headache, skin rash, bulin S\/D, Gammar- back pain, wheezing, Neuropathic IV, Iveegam tachycardia, nausea, and pain hypotension Hypersen- acetaminophen Tylenol with Lightheadedness, sitivity and with codeine codeine dizziness, drowsiness, and neuropathic nausea pain Muscle gabapentin Neurontin Low white blood cell spasms counts, nausea, vomiting, carbamazepine Tegretol and dizziness diazepam Valium Drowsiness, dizziness, blurred vision, impaired coordination and balance, short-term memory loss 302","303 Nonprogressive Disorders of the Spinal Cord (Spinal Cord Injury [SCI]) Description\/Overview Neurological Involvement Types (in Alphabetical Order) Anterior cord syndrome \u2013 motor function, pain, & temperature loss below lesion level Brown-S\u00e9quard syndrome \u2013 spinal cord hemisection showing ipsilateral side motor involvement & proprioception loss, & contralateral side pain & temperature loss Motor loss Proprioception loss Pain and Motor loss temperature loss Pain and temperature loss Cauda equina injury \u2013 similar symptoms to peripheral nerve injury (with specific spinal nerve root involvement) Central cord syndrome \u2013 more severe motor involvement than sensory involvement; upper limbs more involved than lower limbs; common in the elderly & individuals with narrow spinal canals Conus medullaris syndrome \u2013 may present with both UMN & LMN symp- toms, including lower limb paralysis & areflexic bowel & bladder; some patients may retain sacral reflexes SCI","SCI Posterior cord syndrome (very rare today) \u2013 loss of proprioception & 2-point discrimination below lesion level Proprioception loss Sacral sparing \u2013 the most centrally-located sacral tract is spared; perianal sensation & external anal sphincter remain intact (often observed in incomplete cervical lesions) Medical Red Flags Autonomic Dysreflexia Occurs most often in patients with injuries above T6 Symptoms Possible Causes Management \u2022 Flushed face \u2022 Impacted bowel \u2022 Identify & remove cause \u2022 Monitor blood pressure \u2022 Headache \u2022 Full urinary bladder & heart rate \u2022 Profuse sweating \u2022 Blocked urinary \u2022 Keep patient sitting up \u2022 Notify physician (may above lesion level catheter need blood pressure \u2022 Very high blood \u2022 Urinary tract infection medication) \u2022 If unresolved in pressure \u2022 Noxious stimulus 10 minutes, call for emer- gency medical help \u2022 Bradycardia below lesion level \u2022 Skin rash (e.g., ingrown toenail) 304","305 Orthostatic Hypotension (Postural Hypotension) Occurs most often in patients with tetraplegia Symptoms Possible Causes Management \u2022 Sudden blood \u2022 Poor distal & lower \u2022 Recline patient & elevate lower limbs pressure drop limb venous return \u2022 Constantly monitor blood due to position \u2022 Unable to regulate pressure during position changes changes (e.g., from blood pressure \u2022 Have patient wear supine to sitting) pressure stockings & abdominal binder Deep Vein Thrombosis (DVT) Occurs most often in lower limbs Symptoms Possible Causes Management \u2022 Swelling, heat, \u2022 Thrombus formed in \u2022 Rest & no lower limb erythema in deep leg veins due to exercises involved area immobilization \u2022 Refer to physician \u2022 May not feel pain \u2022 Sensory impairment when testing for regarding negative Homans\u2019 sign Homans\u2019 sign (calf muscle pain when passively dorsi-flexing ankle with knee extended) SCI","SCI Precautions Heterotopic Ossification Osteogenesis of soft tissue below injury level Symptoms Possible Causes Management \u2022 Pain, local \u2022 Spur formation in \u2022 Perform gentle ROM swelling\/warmth, or sometimes intra-articular space or exercises blockage of movements soft tissue around joint \u2022 Refer to physician during passive range of motion (ROM) exercises (usually bony end feel) Shoulder Pain Often occurs in patients with tetraplegia Symptoms Possible Causes Management \u2022 Shoulder pain \u2022 Rotator cuff tear or \u2022 Assess causes of exacerbated by injury due to overuse shoulder pain movement \u2022 ROM loss due to \u2022 Provide appropriate immobilization during exercise and positioning acute phase management \u2022 Refer to physician 306","307 Urinary Tract Infection Patients with SCI are more susceptible to urinary tract infection Symptoms Possible Causes Management \u2022 Fever \u2022 Urinary tract \u2022 Refer to \u2022 Chills infection physician \u2022 Nausea \u2022 Headache \u2022 Increased spasticity \u2022 Extraordinary pain or burning during urination \u2022 Autonomic dysreflexia \u2022 Dark or bloody urine Vertebral Compression Fracture More common among patients with chronic SCI Symptoms Possible Causes Management \u2022 Extreme back pain in upright \u2022 Osteoporosis of \u2022 Bed rest positions spine \u2022 Refer to physician \u2022 Pain lessens in supine Physical Therapy Examination General Considerations Examiner should \u25a0 Inquire if patient is allowed to perform any neck & trunk movements during examination if patient has had fracture stabilization surgery (spinal orthoses & halo devices often restrict neck & trunk movements) \u25a0 Assess medically cleared weight-bearing status & ROM limitations (patients with tetraplegia may need finger flexor tightness for tenodesis grasp) \u25a0 Monitor initial sitting tolerance (may be limited) \u25a0 For patients with traumatic brain injury, carefully assess cortical & cerebellar function (Tab 4) SCI","SCI History (Refer to Tab 2) \u25a0 Assess pre-injury functional status & activity level \u25a0 Assess home, work, school, & play environments (wheelchair accessibility) & support system \u25a0 Assess injury mechanism \u25a0 Assess date of occurrence \u25a0 Review medical chart for medical & surgical history Vital Signs Considerations \u25a0 Patients with SCI & autonomic nervous system (ANS) involvement may experience body temperature regulation problems because they are unable to sweat below lesion level Assessment \u25a0 Measure BP, HR, RR, & body temperature Potential findings \u25a0 See following sections on Aerobic Capacity\/Endurance; Circulation; and Ventilation & Respiration Tests and Measures Aerobic Capacity\/Endurance Considerations \u25a0 Phrenic nerve (C3\u20135) innervates diaphragm \u25a0 T1\u201312 innervates intercostal muscles Assessment \u25a0 Measure BP, RR, & HR (wrist, carotid, pedal) in supine, sitting, standing, at rest, & during post-exercise \u25a0 If available, review pulse oximetry, blood gas, tidal volume, & vital capacity \u25a0 If possible, conduct upper limb ergometer test 308","309 Potential findings \u25a0 Decreased cardiovascular & pulmonary responses to position changes & exercise (supine \u03fd sitting) \u25a0 Decreased exercise endurance \u25a0 Profuse sweating above lesion level Anthropometric Characteristics Considerations \u25a0 Arm length versus torso length is important for mat & transfer activities (patients with short arms & long torso may need blocks to perform push-ups in long-sitting) Assessment \u25a0 Measure height, weight, BMI, & arm versus trunk length Arousal, Attention, and Cognition Considerations \u25a0 Patients with SCI & sustained head injury may have affected mental status, memory, & attention span Assessment \u25a0 Perform Mini-Mental State Examination (Tab 2) or Rancho Levels of Cognitive Functioning (for patients with traumatic brain injury) (Tab 4) \u25a0 Assess \u25a0 Orientation to time, place, & \u25a0 Mood person \u25a0 Expressive & receptive \u25a0 Short- & long-term memory language \u25a0 Attention Potential findings \u25a0 Depression \u25a0 Low frustration tolerance Assistive and Adaptive Devices Considerations \u25a0 Patients with SCI may need assistive or adaptive devices for ADLs (e.g., wheelchair, transfer board, hair\/tooth brush, feeding utensils with built-up handles) SCI","SCI Assessment \u25a0 Assess assistive & adaptive device fit, alignment, & safety \u25a0 Assess ability to use assistive & adaptive devices \u25a0 Administer Wheelchair Checklist (see http:\/\/davisplus.fadavis.com) for fitting \u25a0 Assess ability to maintain assistive & adaptive devices (including wheelchair) Circulation Assessment \u25a0 Measure wrist & pedal pulse \u25a0 Differentiate proximal versus distal (toe & finger) circulation & edema \u25a0 Examine lower limbs for deep vein thrombosis \u25a0 Assess blood pressure in supine, sitting, & standing \u25a0 Measure body temperature \u25a0 Assess pulse, blood pressure, & body temperature in response to exercise Potential findings \u25a0 Area below lesion level may be colder than area above lesion level \u25a0 Movement from supine to sitting & standing may lead to quick blood pressure drop \u25a0 Patients with tetraplegia may have lower baseline blood pressure \u25a0 Patients with SCI may demonstrate poor sitting endurance (prolonged sitting may lead to blood pressure drop) \u25a0 Patients with SCI may demonstrate decreased cardiovascular responses to exercise Cranial and Peripheral Nerve Integrity Considerations \u25a0 Perform comprehensive motor & sensory assessment for patients with SCI to determine the extent of injury & recovery \u25a0 Assess sacral area to determine sacral sparing \u25a0 Key sensory areas (see the following American Spinal Injury Association [ASIA] sensory form)1 310","311 Assessment \u25a0 Grossly check all cranial nerves especially if one suspects traumatic head injury \u25a0 Follow myotomes to assess muscle strength (see the following ASIA motor form)1 listed under Muscle Performance \u25a0 Follow dermatomes to assess sensation \u25a0 Differentiate proprioception & vibration (dorsal column) versus sharp or dull & temperature (lateral spino-thalamic tract) versus light touch (anterior spinothalamic tract) ASIA Sensory Form Level Key Sensory Area Findings (R) Findings (L) C2 Occipital protuberance C3 Supraclavicular fossa C4 Top of acromioclavicular joint C5 Lateral side of antecubital fossa C6 Thumb C7 Middle finger C8 Little finger T4 Nipple line T10 Umbilicus T12 Inguinal ligament at midpoint L2 Mid anterior thigh L3 Medial femoral epicondyle L4 Medial malleolus L5 Dorsum of foot at 3rd MT joint S1 Lateral heel S2 Popliteal fossa S3 Ischial tuberosity S4\u20135 Perianal area Source: American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2002; Chicago, IL, with permission. SCI","SCI Environmental, Home, and Work Barriers Assessment \u25a0 Environment, Home, Work Recommendations Chart (Tab 2) \u25a0 Driver rehabilitation specialists should evaluate patients with SCI for motor vehicle modifications & driving capabilities (for more informa- tion, see Association for Drivers Rehabilitation Specialists Web site at www.driver-ed.org) Ergonomics and Body Mechanics Considerations \u25a0 Patients with SCI are more susceptible to upper limb overuse injuries, especially shoulders, when manually propelling a wheelchair & per- forming transfers Assessment \u25a0 Assess wheelchair propulsion on level & uneven surfaces & ramps, through open & closed doors, during transfers, & in community \u25a0 Assess bed level mobility skills (rolling, coming up to sit, long-sitting, & moving from side-to-side in long-sitting) Potential findings \u25a0 Patients with SCI may have shoulder overuse problems or injuries Gait, Locomotion, and Balance Considerations \u25a0 Evaluate location of center of mass in reference to the body (e.g., center of mass is posterior to the hips in long-sitting with shoulders in extension & external rotation & elbows in extension) Assessment \u25a0 Assess balance with & without perturbation (long-sitting on mat, short-sitting over mat edge, short-sitting in chair & standing) \u25a0 Conduct modified Functional Reach Test to assess balance: patient short-sits over a mat table (hip, knee, & ankle at 90\u00b0) & reaches forward; patient can use non-reaching hand for balance & should be guarded carefully during the test2 \u25a0 Examine gait with orthotics & ambulatory assistive devices 312","313 \u25a0 Assess self-propelled & motorized wheelchair mobility (i.e., level surfaces, turns, wheelies, open & closed doors, & up & down ramps & stairs) \u25a0 Assess pressure relief skills in wheelchair (push-up & forward & lateral lean) \u25a0 If mobility-dependent, check if patient can independently direct care-giver Integumentary Integrity Considerations \u25a0 Up to 80% of patients with SCI will experience pressure sores at some point \u25a0 Lingering redness or breakdown within 30 minutes of pressure relief indicates pressure sore onset Assessment (Refer to Tab 2 for Classification of Pressure Sores) \u25a0 Pressure relief techniques \u25a0 Skin twice daily \u25a0 Seating system adequacy to avoid sacral sitting posture \u25a0 Need of patient with SCI for long-handled mirror to check back & buttocks Joint Integrity and Mobility Assessment \u25a0 Determine passive ROM of upper & lower limb joints Potential findings \u25a0 In a patient with SCI, examiner may notice a click or block in joint when performing passive ROM exercises if patient has heterotopic ossification; hips and knees are the most common sites \u25a0 Patients with tetraplegia may demonstrate shoulder impingement syndrome Motor Function Assessment \u25a0 Hand function (dexterity, coordination, & agility) in ADLs \u25a0 Hand function in donning & doffing orthotic & protective devices \u25a0 Hand function for wheelchair mobility & ambulation skills SCI","SCI Potential findings \u25a0 Patients with tetraplegia may use tenodesis in ADLs Muscle Performance Considerations \u25a0 Stabilize joints of patient with SCI while assessing muscle strength to prevent substitution \u25a0 Depending on the level of lesion, patients with SCI may substitute \u25a0 Shoulder external rotation for elbow extension \u25a0 Wrist extension with tenodesis grasp for finger flexion \u25a0 Hip flexion for knee flexion Assessment \u25a0 Follow myotomes to assess muscle strength for bed level activities, wheelchair mobility skills, ADLs, & ambulation \u25a0 Determine muscle strength at key motor levels (see the following ASIA motor form)2 ASIA Motor Form Level Key Muscles Findings (L) Findings (R) C5 Elbow flexors C6 Wrist extensors C7 Elbow extensors C8 Finger flexors (distal phalanx of middle finger) T1 Little finger abductor L2 Hip flexors L3 Knee extensors L4 Ankle dorsi-flexors L5 Long toe extensors S1 Ankle plantar-flexors American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2002; Chicago, IL, with permission. 314","315 Orthotic, Protective, and Supportive Devices Assessment \u25a0 Assess orthotic, protective, & supportive device & equipment fit & alignment (e.g., ankle or foot orthosis) \u25a0 Determine safety during orthotic, protective, & supportive device & equipment use \u25a0 Examine ability to maintain orthotic, protective, & supportive device & equipment Pain Assessment \u25a0 Administer Universal Pain Assessment Tool & Ransford Pain Drawing (see Tab 2) \u25a0 Assess pain according to dermatomes (see Tab 2) Potential findings \u25a0 Pain or paresthesia \u25a0 Traumatic pain during acute phase due to bone or soft tissue injury \u25a0 Pain due to nerve root compression (dermatome distribution) \u25a0 Spinal cord dysesthesias (burning, numbness, pins & needles, or tingling sensation below lesion level) \u25a0 Sharp back pain resulting from renal calculi Posture Assessment \u25a0 Examine posture alignment & symmetry in long- & short-sitting (in wheelchair) & standing Potential findings \u25a0 Patients with high-level paraplegia or tetraplegia often long-sit with back rounded to keep center of mass within support base Range of Motion Assessment \u25a0 Assess passive & active ROM \u25a0 With hip at 90\u00b0, assess hamstring length in supine & then gradually extend knee SCI","SCI Potential findings \u25a0 Patients with SCI must have sufficient range in \u25a0 Shoulder extension, external rotation, & scapular adduction for weight-bearing in long-sitting \u25a0 Elbow & wrist extension & forearm supination for support in long-sitting \u25a0 Hip flexion (greater than 90\u00b0) for sitting \u25a0 Hip extension (at least 10\u00b0) for ambulation \u25a0 Ankle dorsiflexion (at least neutral or better than 10\u00b0) for standing & ambulation \u25a0 Patients with tetraplegia need tenodesis for functional grasping & gripping \u25a0 Patients with SCI need sufficient hamstring length (hip 90\u00b0, knee at least 110\u00b0) for dressing & transfer activities Range of Motion Form Joint ROM Needed Findings (R) Findings (L) Shoulder extension \u03fe 50\u00b0 Hip extension \u03fe 10\u00b0 Hip flexion \u03fe 90\u00b0 Knee flexion \u03fe 110\u00b0 Ankle dorsiflexion \u03fe neutral 316","317 Reflex Integrity Considerations \u25a0 Spinal shock \u2013 patients with SCI may demonstrate areflexia (no DTR below involvement level including no response to digital anal stimu- lation) for a few days or weeks, post-injury \u25a0 Examiner must differentiate between flaccidity & spasticity Assessment \u25a0 Muscle tone \u25a0 DTRs \u25a0 Clonus Potential findings \u25a0 Patients with cervical, thoracic, or lumbar neurological level injury may demonstrate spasticity, clonus, & increased DTR below the level of lesion \u25a0 Patients with cauda equina injury may demonstrate flaccidity Self-Care and Home Management Assessment \u25a0 Assess bed level mobility (rolling, moving up & down in supine, coming to sit, & moving sideways in long-sitting) \u25a0 Assess transfer, including head & trunk & hips relationship, dependency, sliding board, modified stand pivot, stand pivot, forward & sit-to-stand. PT must note transfer surface level, including transfer in & out of driver\u2019s seat if patient drives independently \u25a0 Assess ADLs & IADLs performance abilities with & without assistive, adaptive, orthotic, protective, & supportive devices & equipment \u25a0 Assess self-care & home management safety \u25a0 Administer Functional Independence Measure (accessed at: http:\/\/www.tbims.org) \u25a0 Assess bowel & bladder control (Tab 2) Potential findings Patients with SCI may: \u25a0 Have a reflexive bladder during spinal shock or when the sacral reflex arc (S2\u20134) is damaged; overflowing bladder leads to urine dripping SCI","SCI \u25a0 Reflexively empty bladder following recovery from spinal shock or if sacral reflex arc is intact; bladder may empty during strenuous physi- cal activity (e.g., mat exercise or transfer) Sensory Integrity Considerations \u25a0 Assess combined & cortical sensation if the patient has traumatic head injury Assessment \u25a0 Determine tactile discriminatory, vibration, & joint position sense Potential findings \u25a0 Patients with posterior cord syndrome may demonstrate joint position sense & tactile discriminatory sensation deficits Ventilation and Respiration Considerations \u25a0 Phrenic nerve (C3\u20135) innervates diaphragm \u25a0 T1\u201312 innervate intercostal muscles \u25a0 T6\u201312 innervate abdominal muscles Assessment (Refer to Tab 2) \u25a0 Perform auscultation to check breath sounds of each lobe \u25a0 Use spirometer to assess tidal volume, vital capacity in supine, sitting, & standing \u25a0 Assess respiratory muscle strength & breathing pattern \u25a0 Assess coughing ability \u25a0 Review blood gases from chart \u25a0 Use pulse oximeter to assess blood oxygen level Potential findings \u25a0 Low voice volume due to decreased pulmonary capacity \u25a0 Decreased tidal volume & vital capacity \u25a0 Decreased respiratory muscle strength \u25a0 Accessory muscle use to aid breathing \u25a0 Decreased coughing ability 318","319 Work, Community, and Leisure Assessment \u25a0 Assess ability to resume work, school, community, & leisure activities with & without wheelchair, modified car, & orthotics \u25a0 Assess ability to gain access to work, school, community, & leisure environments \u25a0 Assess work & school, community, & leisure environment safety \u25a0 Administer Craig Handicap Assessment Reporting Technique (CHART, accessed at: http:\/\/www.tbims.org\/combi\/chart\/index.html) \u25a0 Consider U.S. Department of Labor-provided guidelines for job accommodations (accessed at: http:\/\/www.dol.gov\/dol\/topic\/disability\/ ada.htm) & to assess work reintegration Disease-Specific Tests and Measures ASIA Impairment Scale Classification Type Impairment A Complete No motor or sensory function is preserved in the sacral segments S4 to S5 B Incomplete Sensory but not motor function is preserved C Incomplete below the neurological level & includes the sacral segments S4 to S5 D Incomplete Motor function is preserved below the E Normal neurological level & more than half of key muscles below the neurological level have a muscle grade less than 3 Motor function is preserved below the neurological level & at least half of key muscles below the neurological level have a muscle grade of 3 or more Motor & sensory function are normal Source: American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2002; Chicago, IL, with permission. SCI","SCI To find ASIA forms go to http:\/\/davisplus.fadavis.com. Zone of Partial Preservation If a patient has motor & sensory function below the neurological level but does not have function at S4\u2013S5, the area of intact motor & sensory func- tion below the neurological level is termed a \u201czone of preservation.\u201d Medications Indications Generic Name Brand Name Common Side Effects Immediate methylpred- Medrol, Very rare with short-term post-injury nisolone secondary Solu-medrol use damage baclofen Lioresal Drowsiness, weakness, Spasticity either orally dizziness or intrathecal dantrolene Dantrium Drowsiness, weakness, sodium dizziness tizanidine Zanaflex Dizziness, GI problems botulinum BTX Hypotonia, weakness toxin\u2013A Abnormal bleeding, gas, tiredness (injected locally) Deep vein warfarin Coumadin, thrombosis Jantoven, Marevan, Waran Flaccid heparin Heparin Abnormal bleeding, heavy bladder bethanechol Urecholine menstrual bleeding, easy bruising Upset stomach, dizziness, excessive sweating 320","321 Medications\u2014Cont\u2019d Indications Generic Name Brand Name Common Side Effects Spastic propantheline Pro-Banthine Dry mouth, dizziness, bladder drowsiness oxybutynin Ditropan, Dry mouth, dizziness, Ditropan XL constipation tolterodine Detrol Dry mouth, abdominal pain, constipation Urinary antibiotics Cipro Stomach\/intestinal system irritation infection (ciprofloxacin) Nausea, upset stomach, Heterotopic etidronate Didronel painful joints ossification disodium SCI","REF References Tab 3: Pediatric Disorders 1. Bax M, Goldstein M, Rosenbarum P, et al. Proposed definition and classi- fication of cerebral palsy. Dev Med Child Neurol. 2005;47:571\u2013576. 2. Rimmer JH. Physical fitness levels of persons with cerebral palsy. Dev Med Child Neurol. 2001;43:208\u2013212. 3. Committee on Injury and Poison Prevention. Injuries associated with infant walkers. Pediatrics. 2001;108:790\u2013792. Available at: http:\/\/pediatrics.aappublications.org\/cgi\/reprint\/108\/3\/790.pdf. Accessed March 7, 2007. 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington DC: American Psychiatric Association; 1994. 5. National Institute of Neurological Disorders and Stroke. Available at: http:\/\/www.ninds.nih.gov\/disorders\/epilepsy\/epilepsy.htm. Accessed June 16, 2008. 6. Ager S, Fyfe S, Christodoulou J, Jacoby P, Schmitt L, Leonard H. Predictors of scoliosis in Rett Syndrome. J Child Neurol. 2006;21(9):809\u2013813. Tab 4: Nonprogressive CNS Disorders 1. Gordon NF, et al. Physical activity and exercise recommendations for stroke survivors. Circulation. 2004;109:2031\u20132041. 2. Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind, S. The post stroke hemiplegic patient. A method for evaluation of physical performance. Scand J Rehabil Med. 1975;7:13\u201331. 3. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med. 2005:15(2);48\u201355. 322","323 Tab 5: Progressive CNS Disorders 1. NCI. Adult brain tumors (PDQ\u00ae): treatment. National Cancer Institute Web site. August 6, 2007. Available at: http:\/\/www.cancer.gov\/cancertopics\/ pdq\/treatment\/adultbrain\/healthprofessional. Accessed August 6, 2007. 2. USDHHS. Guidelines for the use of anti-viral agents for HIV-1-infected adults and adolescents. National Institute of Health Web site. October 10, 2006. Available at: http:\/\/aidsinfo.nih.gov\/ContentFiles\/AdultandAdolescentGL.pdf. Accessed August 15, 2007. 3. Factor SA, Weiner WJ. Hyperkinetic movement disorders. In: Weiner WJ, Goetz CG, eds. Neurology for the Non-Neurologist. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2004:175\u2013184. 4. CDC. Learn about Lyme disease. Centers for Disease Control and Prevention Web site. June 18, 2007. Available at: http:\/\/www.cdc.gov\/ ncidod\/dvbid\/lyme\/index.htm. Accessed August 23, 2007. 5. Calabresi PA. Multiple sclerosis. In: Weiner WJ, Goetz CG, eds. Neurology for the Non-neurologist. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2004:113\u2013137. 6. Weiner WJ, Shalman LM. Parkinson\u2019s disease. In: Weiner WJ, Goetz CG, eds. Neurology for the Non-Neurologist. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2004:138\u2013154. Tab 6: Peripheral Nerve Injury 1. Bensalem MK, Berger JR. Neurologic complications of human immuno deficiency virus infection. In: Weiner WJ, Goetz CG, eds. Neurology for the Non-neurologist. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2004:510\u2013531. 2. USDHHS. Guidelines for the use of anti-viral agents for HIV-1-infected adults and adolescents. National Institute of Health Web site. October 10, 2006. Available at: http:\/\/aidsinfo.nih.gov\/ContentFiles\/AdultandAdolescentGL.pdf. Accessed August 15, 2007. 3. Fisher MA. Peripheral neuropathy. In: Weiner WJ, Goetz CG, eds. Neurology for the Non-neurologist. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2004:215\u2013234. REF","REF 4. Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007; 356:2245\u20132256. 5. NINDS. Carpal tunnel syndrome fact sheet. National Institute of Neurological Disorders and Stroke Web site. February 12, 2007. Available at: http:\/\/www. ninds.nih.gov\/disorders\/carpal_tunnel\/detail_carpal_tunnel.htm. Accessed September 12, 2007. 6. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992; 107:399\u2013404. Tab 8: Spinal Cord Injuries 1. American Spinal Injury Association. International Standards for Neurological Classification of Spinal Cord Injury, revised 2002; Chicago, IL. 2. Lynch SM, Leahy P, Barker SP. Reliability of measurements obtained with a modified functional reach test in subjects with spinal cord injury. Phys Ther. 1998; 78:128\u2013133. 324","325 Index Page numbers followed by \u201ct\u201d denote tables. Activities of daily living, Katz index Cerebellar degeneration, of, 91t\u201392t 215\u2013219 Alzheimer\u2019s disease, 194\u2013199 Cerebral palsy (CP), 92\u2013101 American Spinal Injury Cerebrovascular accident (CVA), Association (ASIA) 156\u2013158 impairment scale, 319t deep vein thrombosis, 159t motor form, 314 dysphagia, 159t sensory form, 311 medications for, 167t Amyotrophic lateral sclerosis motor assessment scale for, (ALS, Lou Gehrig\u2019s disease), 199\u2013208 168t\u2013173t functional rating scale, neurological status, changes in, 205t\u2013207t 159t Anthropometric characteristics, Clinical Test For Sensory 16\u201318 Interaction in Balance (CTSIB), Autonomic dysreflexia, 304t 44, 45\u201347 Autonomic nervous system Cognitive function, Rancho Los Amigos Levels of, 185t\u2013192 functions, 9t Deep vein thrombosis (DVT), 159t, Balance, Berg Scale, 41t\u201343t 174t, 295t, 305t Balance, Clinical Test For Sensory Dermatomes, 31\u201332 Interaction in (CTSIB), 44 Developmental coordination Bell\u2019s palsy, 255\u2013257 Benign paroxysmal positional disorder (DCD), 104\u2013110 Diagnoses, directory of, 1t\u20134t vertigo (BPPV), 276\u2013281 Dizziness handicap inventory, Berg Balance Scale, 41t\u201343t Borg Rating of Perceived 279t\u2013281t Dysphagia, 159t, 175t Exertion, 15 Dyspnea scale, Medical Research Brain tumor, 208\u2013214 Council, 90t Carpal tunnel syndrome (CTS), Edema rating scale, 22t 267\u2013270 Eng\u2019s System of Classification of Central vestibular dysfunction, Recovery, 135t 151\u2013155 Environmental\/home\/work vs. peripheral vestibular dysfunction, 154t\u2013155t recommendations, 34t\u201337t Epilepsy, 111\u2013114 INDEX","INDEX FLACC Scale, 78t Low birth weight, 126 Four-item dynamic gait index, Lumbar nerve roots, segmental 60t\u201362t nerve supply of, 146f Fractures Lyme disease, 230\u2013235 pathological, 141t, 142\u2013150 Medical Research Council vertebral compression, 307t Dyspnea Scale, 90t Galveston Orientation and Medications Amnesia Test (GOAT), 182t\u2013184t alcoholic cerebellar degeneration, 219t Glasgow Coma Scale (GCS), 181, Alzheimer\u2019s disease, 199t 182t amyotrophic lateral sclerosis, pediatric, 184t\u2013185t 208t Bell\u2019s palsy, 263t Growth and Development Chart, brain tumor, 214t Pathways Awareness carpal tunnel syndrome, 270t Foundation, 70t\u201372t central vestibular dysfunction, 155t Gubbay Test of Motor Proficiency, cerebral palsy, 104t 108t\u2013110t cerebrovascular accident, 167t developmental coordination Guillain-Barr\u00e9 syndrome, 295\u2013302 disorder, 110 autonomic disturbances, 296t Guillain-Barr\u00e9 syndrome, 302t deep vein thrombosis, 295t HIV\/AIDS, 224t\u2013225t dysphagia, 296t Huntington\u2019s disease, 229t\u2013230t respiratory distress, 296t Lyme disease, 235t Meniere\u2019s disease, 283t Heterotopic ossification, 175t, 306t multiple sclerosis, 241t\u2013243t HIV infection, 219\u2013225 muscular dystrophy, 125t Parkinson\u2019s disease, 252t\u2013254t peripheral nerve injury of, pathological bone fractures, 150 257\u2013263 pediatric seizure, 114t peripheral neuropathy, 294t Huntington\u2019s disease\/Huntington\u2019s radial nerve injury, 272t Chorea, 225\u2013230 sciatica, 267t spinal cord injury, 320t\u2013321t Hydrocephalus, 115\u2013118 traumatic brain injury, 193t Hypoxic ischemic encephalopathy trigeminal neuralgia, 286t ulnar nerve injury, 276t (HIE), 125 Meniere\u2019s disease, 281\u2013283 Intraventricular hemorrhage (IVH), 125 Ipsilateral paralysis of the diaphragm, 131\u2013135, 131t Katz Index of Activities of Daily Living, 91t\u201392t 326","327 Milani-Comparetti Motor of HIV infection, 257\u2013263 Development Screening Test, of lower limbs, 263\u2013267 102\u2013103 Periventricular leukomalacia (PVL), Mini-Mental State Examination 126 (MMSE), sample items, 19 Physical development, 17\u201318, Mobility index, Rivermead, 68 70t\u201372t Motor Development Screening signs to watch for, 72\u201374 Test, Milani-Comparetti, 102\u2013103 Polyneuropathy Motor function neuroanatomy and autonomic, 287t pathology, 9t axonal, 287\u2013294 Motor proficiency, Gubbay test of, Prematurity, 126\u2013129 108t\u2013110t Pressure sores, classification of, Movement Order Society- 64t Sponsored Revision of the Unified Parkinson\u2019s Disease Radial nerve injury, 271\u2013272 Rating Scale (MDS-UPDRS), Rancho Los Amigos Levels of 250t\u2013252t Cognitive Function, 185t\u2013192 Multiple sclerosis, 235\u2013243 Ransford Pain Drawings, 76 Muscular dystrophy (MD), 118\u2013125 Reach Myelomeningocele, 141 functional, normal values, 40t neurological syndromes with, multi-directional, values for 145t older adults, 41t Reflexes, grading of, 81t Neurological status, changes in, Rett syndrome, 135\u2013139, 136t 159t Rivermead Mobility index, 68 Obstetrical brachial plexus palsy, Sacral nerve roots, segmental 129, 130t nerve supply of, 146f Orthostatic (postural) hypotension, Sciatica, 263\u2013267 174t, 305t Scoliosis, Adam\u2019s Forward Bend Parkinson\u2019s disease, 243\u2013254 Test for, 79 Pathways Awareness Foundation Seizures, 175t Growth and Development Chart, types and descriptions, 70t\u201372t 111t\u2013113t Pediatric balance scale, 54t\u201358t Performance-oriented mobility Sensory function neuroanatomy assessment, 48t\u201351t and pathology, 8t Peripheral nerve injury (PNI), 255\u2013263 Shaken baby syndrome (SBS), Bell\u2019s palsy, 255\u2013257 139\u2013140 Shoulder pain, 306t Spasticity, modified Ashworth Scale for, 82t INDEX","Spina bifida (SB), 140\u2013141 INDEX Spinal cord injury, 303\u2013321 deep vein thrombosis, 174t autonomic dysreflexia, 304t dysphagia, 175t deep vein thrombosis, 305t heterotopic ossification, 175t heterotopic ossification, 306t orthostatic hypotension, 174t impairment scale, 319t seizures, 175t orthostatic hypotension, 305t Trigeminal neuralgia (tic shoulder pain, 306t douloureux), 284\u2013286 urinary tract infection, 307t vertebral compression fractures, Ulnar nerve injury (entrapment), 273\u2013276 307t Universal Pain Assessment Tool, Tests and measures 77 directory of, 4t\u20137t Urinary tract infection, 307t Tinetti\u2019s Falls Efficacy Scale, 59t Traumatic brain injury (TBI), Vertebral compression fractures, 307t 173\u2013193 Vital signs, normal values, 14t 328"]