PT Management in Others Neurological conditions

1. PT Management in Others Neurological conditions Nichapha Chandee School of Ailed Health Science and Puplic Health E-Mail: cnichaph@wu.ac.th, Tel: 084-2408849

2. Others Neurological • Myasthenia gravis • ALS (Amyotrophic Lateral Sclerosis) • MS (Multiple sclerosis) • Guillain-Barre’s Syndrome • Duchenne and Becker Muscular dystrophy • Parkinson’s disease • Cerebellar dysorders

3. Myasthenia gravis • Neuromuscular junction defect • Autoimmune disease Thymoma (Active function of Thymus gl.) • Produce Antibody to nicotinic receptors (NMJ) - Receptor was blocked, damage - Complement of NMJ defect

4. Myasthenia gravis Clinical Features • peaks of incidence : Woman 20-30 and 60-80, Men 50-60 • female : male = 3:2 • The cardinal features are “ Weakness” and “ Fatigability” of muscles • The weakness increases during repeated use and may improve following rest or sleep

5. Myasthenia gravis • Remissions are rarely complete or permanent • Infections or systemic disorders : weakness will be worse and may precipitate “ myasthenic crisis”  respiratory failure • Muscle weakness : • lids and extraoccular muscles, diplopia and ptosis • facial weakness , a “snarling” expression when the patient attempt to smile or facial diplegia

6. Myasthenia gravis • Weakness in chewing, speech, difficulty in swallowing • Proximal weakness of limb muscle • Deep tendon reflex : normal • “ CRISIS” weakness of respiration and require respiratory assistance

7. Myasthenia gravis • DIAGNOSIS • History : diplopia, ptosis, weakness in characteristic distribution, fluctuation during the day, effects of previous treatments • Physical examination : ptosis, diplopia, motor power, FORWARD ARM ABDUCTION TIME (5min), vital capacity, absence of other neurologic signs • Laboratory : anti AChR radioimmunoassay : definite diagnosis if positive

8. PT Management in MG • General exercise (early stage) • PT chest therapy (late stage) - BE (Breathing exercise) - Coughing - Huffing - Chest Trunk Mobilization • Respiratory failure

9. ALS (Amyotrophic Lateral Sclerosis)

10. ALS (Amyotrophic Lateral Sclerosis) • Loss of motor neurons in the cortex, brainstem and spinal cord • Mix of upper motor neuron and lower motor neuron findings • Weakness, atrophy, fasciculations • Slurred speech, difficulty swallowing, shortness of breath • Can start in any extremity or the bulbar musculature • Relentlessly progressive

11. ALS (Amyotrophic Lateral Sclerosis) • 50 % dead in 3 years, 80% dead in 5 years, 5-10% live more than 10 years • Death usually from respiratory failure • Etiology still only theoretical • Excess glutamate • Oxidative stress • Free radicals • Mitochondrial dysfunction

12. ALS (Amyotrophic Lateral Sclerosis)

13. PT management in ALS (Amyotrophic Lateral Sclerosis) • General Exercise: mind/Moderate • Chest Therapy - BE (Breathing Exercise) - Coughing - Huffing - Chest Trunk Mobilization

14. MS (Multiple sclerosis) • Idiopathic disease of suspected autoimmune • Attacks a person's central nervous system (brain and spinal cord), leading to demyelination • Attacks and damages the myelin • Refers to scars (scleroses—better known as plaques or lesions) in the white matter of the brain and spinal cord

15. MS (Multiple sclerosis) • Cause remains unknown • Genetics or infections • Different environmental risk factors

16. MS (Multiple sclerosis) There are three categories of MS; Definite, Probable, and Possible MS. • Definite MS • Probable MS • Possible MS

17. MS (Multiple sclerosis) • Relapse-remitting MS (RRMS): Here you have an attack, go into complete or partial remission, then have the symptoms return. • Primary-progressive MS (PPMS): Here you continually decline and have no remissions. There may be a temporary relief in symptoms. • A few patients have malignant MS which is where they have a quick decline which leaves them severely disabled or even lead to death.

18. MS (Multiple sclerosis) • Secondary-progressive MS (SPMS): This stage of MS starts with RRMS symptoms and continues on to show signs of PPMS. • Progressive-relapsing MS (PRMS): This is a rare form but here it takes a progressive route made worse by acute attacks. • 20% of the people with MS have a benign form. Here they show little progression after the first attack.

19. MS (Multiple sclerosis) • Fatigue • Depression • Memory change • Pain • Spasticity • Vertigo • Tremor • Double Vision/Vision Loss • Weakness • Dizziness/Unsteadiness • Numbness/Tingling • Ataxia • Euphoria • Speech disturbance • Bladder/Bowel/Sexual dysfunction

20. PT management in MS (Multiple Sclerosis) • General Exercise: depend on progression of lesion • Chest Therapy - BE (Breathing Exercise) - Coughing - Huffing - Chest Trunk Mobilization

21. Guillain-Barre’s Syndrome • Most common cause of rapidly progressive weakness • Demyelinating neuropathy • Ascending weakness which may include cranial neuropathies • Exam reveals symmetric weakness with areflexia and large fiber sensory loss • Bowel and bladder usually preserved

22. Guillain-Barre’s Syndrome • Respiratory failure can be precipitous • Other causes of morbidity and mortality • Autonomic instability • DVT • Infection • Immune mediated, may be post infectious • Treatment • Plasma exchange • Intravenous immunoglobulin

23. PT Management in Guillain-Barre’s Syndrome • General Exercise • Pumping Exercise: Prevent DVT • PT Chest Therapy - BE (Breathing Exercise) - Coughing - Huffing - Chest Trunk Mobilization

24. Duchenne and Becker Muscular dystrophy

25. Duchenne’s Muscular Dystrophy Duchenne’s Muscular Dystrophy • X-linked recessive • Absence of dystrophin protein • Slow to reach motor milestones, sxs by age 5 • All walk, may never run • End up in wheelchair by age 10-12 • Steroids may delay time until wheelchair bound • Muscles replaced by fat may appear hypertrophic • Frequently mildly mentally retarded • Life expectancy < 20 years with death related to respiratory failure or cardiomyopathy

26. Duchenne’s Muscular Dystrophy General Appearance • Shoulder arkwardly • Sway back • Scoliosis • Knee bend (locked-knee) • Pseudohypertrophy of calf • Tip-Toe walking • Muscle of LE Atrophy

27. PT Management in Duchenne’s Muscular Dystrophy • Trunk Stabilization exercise • Management of Posture: Scoliosis • Stretching of calf muscle • Exercise for Strengthening of Muscle of LE • Chest PT in late stage

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