Other neurological conditions

Midline (vermis/flocculonodular) lesions mainly cause trunk instability, ataxic gait, and nystagmus; lateral hemisphere lesions mainly cause limb dysmetria, intention tremor, and dysdiadochokinesia. Cerebellar signs appear on the same side as the lesion, and the resulting gait and trunk instability increase fall risk, so guard closely during functional activities.

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.
• Constructional apraxia: a patient cannot draw, construct, or copy an object even though the task is understood and the physical ability to do it is intact.

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
  • Approach and cue the patient from the neglected side during mobility and ADL training to encourage attention to that side
• 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 after brain injury, especially right-hemisphere stroke, and requires close supervision during transfers and mobility to prevent injury
  • 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.

Individuals with encephalitis require bed rest, fluids, and antiviral or anti-inflammatory medications. Physical therapy provides supportive treatment based on the functional deficits presented, but should stop the session and report to the supervising PT and nursing if the patient has a seizure, a declining level of consciousness, new confusion, or worsening headache or fever.

Meningitis is inflammation of the lining of the brain and spinal cord, and its common symptoms are fever, headache, and a stiff neck. Bacterial meningitis, including meningococcal meningitis, usually comes on quickly with fever and chills, severe headache, stiff neck and sensitivity to light.

Neurological conditions and post-COVID

COVID-19 infection increases the risk of secondary neurological conditions: stroke through clotting and reduced perfusion, and encephalitis, transverse myelitis, and Guillain-Barré syndrome through abnormal immune responses. Treatment addresses the secondary diagnosis using the approaches described throughout this chapter.

Bulbar palsy

A stroke in the medulla and motor neuron disease are common causes. A lateral medullary stroke (vertebral or posterior inferior cerebellar artery) affects nerves IX and X but spares the hypoglossal nucleus, so it causes dysphagia, hoarseness and dysarthria without tongue wasting. Dysarthria is difficulty saying words because of problems with the muscles used for speech; the muscles may be weak or completely paralyzed.

• Bulbar palsy (lower motor neuron): severe dysphagia with a reduced or absent gag reflex, flaccid dysarthria, and tongue wasting and fasciculation
• Pseudobulbar palsy (upper motor neuron): from lesions of the corticobulbar tracts on both sides (for example, bilateral strokes); spastic dysarthria, a spastic tongue without wasting or fasciculation, a brisk jaw jerk, and emotional lability
• Bulbar-onset ALS: about 25-30% of ALS begins with dysarthria and dysphagia, with signs of both kinds, and it progresses faster than limb-onset ALS

Dysphagia is managed first with diet texture changes, swallowing exercises and compensatory strategies directed by the speech-language pathologist. A feeding tube, such as a PEG, is added when eating by mouth becomes unsafe or insufficient; in ALS it is placed before vital capacity falls below 50% of predicted. The main risks are aspiration pneumonia, malnutrition and dehydration.

Trigeminal neuralgia

The pain associated with trigeminal neuralgia is neuropathic and can last from a few seconds up to two minutes. It is caused by irritation of the trigeminal nerve, most often from compression by a blood vessel (see types below).

Symptoms

• Sudden, intense pain to one side of the face
• Typically pain-free between attacks; some patients (an atypical form) have continuous burning or aching background pain

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

Treatment by physical therapy may include the use of transcutaneous electrical stimulation (TENS) for pain relief, along with collecting data on and reporting other symptoms to the PT. Medical management may include nerve block, pain medications, or anticonvulsants.

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. Cholinergic neurons of the basal forebrain degenerate, and choline acetyltransferase, the enzyme that makes acetylcholine, is reduced.

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

Delirium begins suddenly, causes fluctuations in mental function, and is usually reversible, whereas dementia begins gradually, progresses slowly, and is usually irreversible. Vascular dementia may progress in steps: symptoms can worsen suddenly and then plateau or lessen somewhat, unlike other dementias, which tend to progress continuously.

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