Other neurological conditions

Common symptoms associated with cerebellar dysfunction

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

Perceptual dysfunction

Examples of perceptual dysfunctions are described below.

Spatial relation disorders

• Causes: stroke, brain injury, Alzheimer’s disease, Parkinson’s disease
• Definition: 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: the hidden-object illustrations in “Where’s Waldo?” books
• Spatial relation deficit disorder: inability to properly space objects in relation to one another
  • Example: an individual has difficulty understanding descriptive spatial terms such as on, over, below, between, or under - for example, understanding that “the book is on the table.”
• Topographical disorientation disorder: inability to navigate a familiar route independently
  • Example: an individual who has difficulty recalling how many left turns to make when driving from home to the grocery store
• Depth/distance perception disorder: unable to accurately judge depth or distance
  • Example: an individual who walks into a wall while ambulating due to an inability to judge distance accurately
• Vertical disorientation disorder: unable to accurately determine what is upright
  • Example: an individual sits or stands leaning to one side while perceiving that they are upright

Agnosia

• Causes: stroke, brain injury, brain abscess
• Definition: 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
• Definition: 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

Types of apraxia

• 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
• Definition: 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 watches their hand typing but does not recognize it as part of their own body
• Visual spatial neglect: ignoring one side of the body and any stimuli from that side
  • Example: a patient with stroke eats food from only one side of the plate or fails to groom or dress the neglected side of the body
• Right/left discrimination disorder: unable to identify the left and right sides of the body
  • Example: an individual asked to step onto the step with the left foot but is consistently unable to identify their 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 despite requiring maximum assistance, leading to injury; this is typically seen in conjunction with a brain injury or in impulsive individuals
  • Neglect and anosognosia often occur together after right-hemisphere stroke but are separate deficits: neglect is failing to attend to one side, while anosognosia is failing to recognize that a deficit exists, so a patient can have neglect and still be fully aware of it

Encephalitis

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

COVID-19 infection increases the risk of secondary neurological conditions - including stroke, encephalitis, transverse myelitis, and Guillain-Barré syndrome - likely due to impaired oxygenation and perfusion. Treatment addresses the secondary diagnosis using the approaches described throughout this chapter and previous chapters.

Trigeminal neuralgia

The pain associated with trigeminal neuralgia is neuropathic and can last from a few seconds up to two minutes. It is typically caused by nerve lesion or injury (as described in the peripheral nerve chapter).

Symptoms

• 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 the face, shaving, or applying makeup), eating, drinking, talking, blowing the nose, brushing teeth, or exposure to wind. Patients can experience these attacks multiple times per day, with intervening periods of remission.

Types of trigeminal neuralgia

• 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, along with 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 affects multiple areas of the brain, especially the temporal (hippocampus) and parietal lobes. The typical age of onset is after 60 years old.

Symptoms

• Loss of declarative (episodic) memory, especially for recently learned information, is typically the earliest symptom; procedural memory is relatively preserved until later stages
• Decreased spatial awareness
• Word-finding difficulty
• Changes in personality and behavior
• Sundowning, a behavioral symptom that tends to emerge in later stages
  • Increased confusion/agitation at the time of sunset

Intervention strategies for individuals with Alzheimer’s disease

• Sessions are to assist with maintaining the current level of function
• Basic ADLs and mobility status
• Providing assistive devices (AD) and durable medical equipment (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

Motor learning principles and detailed intervention progressions for these conditions are covered in the next chapter, Interventions for neurological conditions.