Other neurological conditions

Cerebellar dysfunctions

Cerebellar dysfunction are conditions in which the cerebellum has been damaged leading to deficits in coordination, balance, and motor control. Common causes of cerebellar dysfunction are stroke, tumor, infections, genetic disorders, or nutritional deficits. Symptomatology is based on the part of the cerebellum impacted.

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• Lesions of flocculonodular lobe
  • Central vestibular symptoms- ocular dysmetria, poor eye pursuit, dysfunctional eye pursuit, impaired eye-hand coordination
  • Gait and trunk ataxia
• Lesions of spinocerebellum, rostral cerebellum, and anterior lobe
  • Hypotonia
  • Weakness and fatigue
  • Truncal ataxia
  • Ataxic gait
• Lesions of neocerbellum
  • Intention tremor
  • Dysdiadochkinesia
  • Dysmetria
  • Dyssynergia

Common symptoms also associated with cerebellum dysfunction:

• Asthenia
• Motor learning impairments
• Cognition deficits for processing and attention to tasks
• Emotional dysregulation

Definitions

Dysmetria

Errors of force, direction, and/or amplitude when performing an activity; hypermetria- overshooting target when attempting to move; can be further defined as: hypometria- undershooting target movement when attempting to move

Ataxia

Lack of muscle coordination, resulting in uncoordinated, clumsy movements

Dysdiadochokinesia

Inability to perform rapid, alternating movements

Dyssynergia

Lack of coordination between muscles

Asthenia

Generalized weakness and/or lack of energy and strength

Perception dysfunction

Perceptual dysfunctions are impairments causing mobility deficits that cannot be directly contributed to loss of sensory, motor, or comprehension abilities. Individuals are unable to process the input of the environment which leads to difficulty in reacting appropriately to the environment. Examples of perceptional deficits are listed as follows.

Spatial relation disorders

• Causes: stroke, brain injury, Alzheimer’s disease, Parkinson’s disease
• Define: difficulty with interpreting information of where on object is in relation to another object in the environment
• Effects: dependent on type of spatial disorder

Types of spatial relation disorders:

• Figure-ground discrimination disorder: inability to perceive an object against background
  • Example: “Where is Waldo” comics
• Spatial relation deficit disorder: inability to properly space on object in relationship from another
  • Example: an individual demonstrates difficulty with descriptive terms such as on, over, below, between, under , etc such as “the book is on the table.”
• Topographical disorientation disorder: inability to navigate a familiar route independently
  • Example: an individual with difficulty recalling how many left turns to drive from home to grocery store
• Depth/distance perception disorder: unable to accurately judge depth or distance
  • Example: an individual walking into wall when ambulating due to inability to judge distance accurately
• Vertical disorientation disorder: unable to accurately determine what is upright
  • Example: an individual sits or stands quickly while performing head turns can lead to vertical disorientation

Agnosia

• Causes: stroke, brain injury, brain abscess
• Define: inability to recognize familiar objects with one sensory modality
  • Example: unable to name a pencil in hand with eyes closed
• Effect: Need to utilize more than one sensory modality when naming an object

Apraxia

• Causes: stroke, brain injury, Alzheimer’s disease, Parkinson’s disease
• Define: difficulty performing purposeful movements when normal range of motion, strength, and comprehension are present
• Effects: Breaking down complex movements to smaller movements, increasing verbal and visual cues, increasing repetition

Body scheme/image disorders

• Causes: brain injury, brain abscess, developmental delay
• Define: difficulty with understanding body segments in relationship to environment
• Effects: dependent on type of body scheme disorders

Types of body scheme/image disorders

• Body scheme disorder (asomatognosia): inability to recognize a body part as your own
  • Example: individual visualizes had typing but does not associate the hand as part of their own body
• Visual spatial neglect: ignoring one side of the body and any stimuli from that side
  • Example: individuals with stroke who exhibit pusher syndrome
• Right/left discrimination disorder: unable to identify left and right sides of the body
  • Exampled: individual asked to step up onto step with left but consistently is unable to identify left lower extremity
• Anosognosia: denial of neglect or lack of awareness of severity of dysfunction
  • Example: individual attempts to transfers without assistance but is maximum assistant - leads to injury and is typically in conjunction with brain injury or impulsive individual

Encephalitis

Encephalitis is inflammation of the brain due to infection. Primary symptoms are headache, fever, body aches, fatigue, weakness, confusion, agitation, seizures, loss of sensation, and loss of consciousness. Diagnosis is made by medical history, imaging, and labs.

Individuals with encephalitis will require bed rest, fluids, anti-inflammatory mediations, and antiviral medications. Physical therapy will provide supportive treatment based on functional deficits presented.

Neurological conditions and post- COVID

Individuals after COVID diagnosis may experience damage to the nervous system. The direct link between COVID and the nervous system is not fully understood but research suggests that due to the widespread damage used by deficiency in oxygenation and profusion (by blood vessels) the individuals are at increased risk for developing secondary neurological conditions. Such conditions are stroke, encephalitis, transverse myelitis, or Gillian-Barre syndrome.

Treatment of neurological conditions associated with COVID would be management of secondary diagnosis as described in this chapter and previous chapters.

Transverse myelitis

Transverse myelitis is inflammation of the spinal cord in which the myelin sheath is damaged. The damage can result in varied levels of neurological deficits dependent upon the level of injury.

Transverse myelitis can be caused by viral or bacterial infection, autoimmune disorders, or certain medications. Diagnosis is confirmed via imaging and lab tests. When differentiating spinal cord injury vs transverse myelitis , individuals with spinal cord injury symptomatology developed quickly after direct trauma whereas individuals with transverse myelitis developed symptoms over a short period of time.

Symptoms include:

• Weakness in arms, legs, and/or trunk
• Sensory loss
• Incontinence of bladder and/or bowel
• Muscle spasms
• Back pain

Treatment by physical therapy includes management of symptoms as presented and related to functional impairments. Individuals with transverse myelitis can have a full recovery to normal if inflammation is controlled, Medical management includes use **of corticosteroids for inflammation and immunosuppressants for infectious processes that may be present. **

Bulbar palsy

Bulbar palsy is the paralysis of the nerves that innervate muscles in the face, throat, larynx, and tongue. The cranial nerves affected are glossopharyngeal (IX), vagus (X), accessory (XI), and hypoglossal (XII). Causes of bulbar palsy can be brainstem stroke or tumor, amyotrophic lateral sclerosis (ALS), autoimmune disorders, or genetic conditions.

Symptoms include:

• Loss of gag reflex
• Excessive drooling
• Difficulty swallowing
• Difficulty articulating words
• Difficulty chewing
• Atrophy of tongue

Diagnosis is confirmed via clinical examination, imaging, and lab tests. Further diagnosis may be needed if the underlying cause of bulbar palsy has not been identified. Speech therapists play an integral role in bulbar palsy. Treatment by physical therapy includes management of symptoms as presented and related to functional impairments. Medical management includes treatment for underlying diagnosis and medication** management by corticosteroids and immunosuppressants. Individuals may also require use of a feeding tube if difficulty swallowing is not resolved and malnutrition is identified. **

Trigeminal neuralgia

Trigeminal neuralgia is a chronic pain disorder in which the trigeminal nerve (cranial nerve V) is damaged - trigeminal is the main sensory nerve to the face. The pain associated with trigeminal neuralgia is a neuropathic pain that can last for a few seconds up to two (2) minutes. Trigeminal neuralgia is typically caused by nerve lesion or injury (as described in the peripheral nerve chapter).

Symptoms include:

• Sudden, intense pain to one side of the face
• Burning, throbbing, numbness, tingling, or dull aching sensation in between attacks

The pain can be exacerbated by rubbing the cheek (when washing face, shaving, or applying makeup), eating, drinking, talking, blowing nose, brushing teeth, or face interaction with wind. The patient can experience it multiple times per day over a period of time with times of remission.

Two types of trigeminal neuralgia can present:

• Primary: caused by compression of a blood vessel against trigeminal nerve
• Secondary: caused by stroke, multiple sclerosis, or tumor

Diagnosis is confirmed via clinical examination and imaging. **Treatment by physical therapy may include use of transcutaneous electrical stimulation (TENS) for pain relief and assessment of any other symptoms that may impair function. **Medical management may include nerve block, pain medications, and anticonvulsants to treat pain.

Alzheimer’s disease

Alzheimer’s disease is a progressive neurodegenerative disorder that slowly impairs executive function and memory leading to complete debility. Alzheimer’s impacts multiple areas of brain in

frontal and temporal lobes The typical age of onset is after 60 years old.

Symptoms include:

• Sundowning is first symptom
  • Increased confusion/agitation at time of sunset
• Loss of declarative and procedural memory
• Decrease spatial awareness
• Word finding difficulty
• Changes in personality and behavior

Intervention strategies for individuals with Alzheimer’s disease are as follows:

• Sessions are to assist with maintaining current level of function
• Basic ADLs and mobility status
• Providing AD and DME as appropriate
• Management of behaviors
• Be consistent in routine (blocked routine)
• Closed environment to minimize distractions
• De-escalate aggressive or combative behaviors by changing current task
• Re-orient as appropriate