Other neurological conditions | Neuromuscular system

Cerebellar dysfunctions

Cerebellar dysfunction is a condition 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 affected.

Common symptoms associated with cerebellum dysfunction:

Ataxic gait
Trunk instability
Intention tremor
Dysdiadochokinesia
Dysmetria
Motor learning impairments
Cognitive deficits for processing and attention to tasks
Hypotonia
Weakness and fatigue

Definitions

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

Perception dysfunction

Perceptual dysfunctions are impairments that cause mobility deficits and cannot be directly attributed to a 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 perceptual deficits are listed as follows.

Spatial relation disorders

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

Types of spatial relation disorders:

Figure-ground discrimination disorder: inability to perceive an object against a background
- Example: “Where is Waldo” comics
Spatial relation deficit disorder: inability to properly space objects in relation to one 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 the grocery store
Depth/distance perception disorder: unable to accurately judge depth or distance
- Example: an individual walking into a wall when ambulating due to an inability to judge distance accurately
Vertical disorientation disorder: unable to accurately determine what is upright
- Example: an individual sitting or standing 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
Effects: Needs 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 the normal range of motion, strength, and comprehension is present
Effects: Breaking down complex movements to smaller movements, increasing verbal and visual cues, and increasing repetition

2 Common types:

Ideomotor Apraxia: difficulty translating the idea of a movement into motor commands. Individuals may struggle to perform tasks such as waving, blowing a kiss, or licking their lips.
Ideational Apraxia: inability to plan and sequence complex movements, such as dressing or brushing teeth.

Body scheme/image disorders

Causes: brain injury, brain abscess, developmental delay
Define: difficulty with understanding body segments in relationship to the environment
Effects: dependent on the 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: an individual visualizes having a hand 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 the left and right sides of the body
- Example: an individual asked to step up onto the step with the left but consistently is unable to identify the left lower extremity
Anosognosia: denial of neglect or lack of awareness of the severity of the dysfunction
- Example: an individual attempts to transfer without assistance, but is a maximum assistant, which leads to injury and is typically in conjunction with a brain injury or an 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 medications, and antiviral medications. Physical therapy will provide supportive treatment based on the functional deficits presented.

Neurological conditions and post- COVID

Individuals after a 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 caused by a deficiency in oxygenation and perfusion (by blood vessels), individuals are at increased risk for developing secondary neurological conditions. Such conditions are stroke, encephalitis, transverse myelitis, or Guillain-Barré syndrome.

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

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 the trigeminal nerve
Secondary: caused by stroke, multiple sclerosis, or tumor

Diagnosis is confirmed via clinical examination and imaging. Treatment by physical therapy may include the 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 the brain, especially the frontal and temporal lobes. The typical age of onset is after 60 years old.

Symptoms include:

Sundowning is the first symptom
- Increased confusion/agitation at the time of sunset
Loss of declarative and procedural memory
Decreased 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 the 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 the current task
Re-orient as appropriate