Rehab Medicine Flashcards

0
Q

How is most at risk of MS?

A

Women (2x as likely)
Between the age of 20-50
Living in countries towards the poles

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1
Q

What is the most common pattern of MS?

A

Relapsing remitting pattern:

Two episodes of neurological impairment affecting two different parts if the CNS, each lasting longer than 24 hours and occurring at least one month apart

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2
Q

How long do the effects of inpatient rehabilitation last for MS?

A

Physical and psychological benefits last 6 months

Neuro status and functioning diminishes after discharge

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3
Q

What should the outpatient rehab for MS involve?

A

For relapsing remitting:

IV corticosteroids combined with rehab provides improvements lasting at least three months

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4
Q

How can fatigue me managed in MS?

A

Ensure sleep hygiene
Exclude medical problems - hypothyroidism, infection
Review medication that may worsen fatigue - baclofen, carbamazepine
Adaptive equipment
Work simplification
Training energy conservation techniques

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5
Q

How should sphincter disturbance in MS be managed?

A

Rule out UTI

If prone to retention, teach intermittent self-catheterisation

Overnight symptoms may respond to low dose ADH (desmopressin)

Detrusor hypereeflexia (frequent small volume voiding) - treat with oxybutynin, tolterodine, intavesical botulinum toxin

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6
Q

What functions are impaired in frontal lone stroke?

A

Personality, expression, movement
Speech and writing - may be damaged

Motor:
Hemiparesis - face, trunk, limbs 
Sitting to standing, standing, walking
Abnormal tone
Flaccid, spasticity
Lack of coordination
Loss of dexterity, fine finger movements
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7
Q

What functions may be impaired in parietal line stroke?

A

Sensation:
may be loss or abnormal sensation
may be perceived as pain
proprioception may be lost compounding limitation of movement

Praxis:
ability to carry out skilled movements

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8
Q

What is praxis?

A

Ability to carry out skilled movements

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9
Q

Where is praxis located?

A

Dominant temporo-parietal cortex

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10
Q

What is apraxia?

A

Loss of skilled movement ability when not explained by weakness, sensory loss or innattention

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11
Q

What is involved in stroke rehabilitation?

A

Improvement in safe transfers, eg between bed and chair

Independent mobility - training with walking aiding roving abilities in ADL

Return to participation in work or leisure

Prevention of further strokes

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12
Q

What are the main types if perceptual impairment after stroke?

A

Inattention
Visual agnostic
Visual neglect/hemineglect

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13
Q

Now long should visually impaired stroke patients wait before driving?

A

In attention and neglect prevent patients from driving

Advise not to drive for minimum of one month, or until impairment resolves if takes longer than one month

Longer for drivers of commercial vehicles

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14
Q

In what types of injuries is spinal cord injury assumed?

A

Motor vehicle crash
Fall from height
Incidents with impact, crushing, multiple trauma
Loss if consciousness

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15
Q

What symptoms are suspicious of spinal cord injury?

A

Back or neck pain
Guarding of back or neck
Sensory changes/loss/numbness/tingling
Being unable to pass urine

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16
Q

What is the MRC grading to rate motor movements on each side of the body?

A
0- total paralysis
1- palpable or visible contraction
2- active movement with gravity
3- active movement against gravity
4- moderate movement against gravity
5- full normal movement
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17
Q

How is sensation graded?

A

0 - no sensation
1 - abnormal or impaired sensation
2 - intact sensation

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18
Q

What is complete spinal injury?

A

Patient lacks motor AND sensation at anus

Innervated by S4-5

Usual more severe

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19
Q

What is incomplete spinal injury?

A

Patient has motor OR sensation at anus

Usually a better prognosis

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20
Q

What is the AISA impairment scale?

A

1 - complete - no sensorimotor at anus

2- sensory NOT motor function below neurological level, extends through S4-5

3- motor function preserved below neuro level, most muscle 3

5- normal - sensory and motor functions are normal

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21
Q

What are the long term consequences of spinal cord injury?

A

Spasticity
Osteoporosis
Heterotrophic ossification of soft tissues around joints
Renal failure - renal calculi due to repeat UTIs
Respiratory failure - patients cannot ventilate lungs

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22
Q

At lesions above what neurological level do autonomic complications occur?

A

Lesions above T7

Due to loss of sympathetic input (esp to heart) from sympathetic chain in cervical and upper half of thoracic spinal cord

Parasympathetic input from vagus is preserved

Results in hypotension and bradycardia

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23
Q

What is vagal stimulation induced cardiac arrest?

A

Upper airway suctioning, ng tubes and intubation cause reflex increased vagal output

This causes bradycardia and and cardiac arrest

Treat with prophylactic atropine before procedure

Impact of vagal stimulation decreases after a month - can use pacemaker if persists

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24
Q

What is the mechanism behind autonomic dysreflexia?

A

Due to uncontrolled reflex sympathetic activity to noxious stimuli below level of SCI

Results in reflex hypertension, which would normal be countered by vasodilation in lower limbs

Injury disrupts outgoing autonomic signals from BP centres in brainstem

May result in cerebral haemorrhage, seizure and death

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25
Q

What factors might precipitate autonomic dysreflexia?

A
Bladder - UTI, over distension, stones
Bowel distension- constipation etc
Pressure sores
Ingrown toenails
Complications of pregnancy and labour
Sexual activity
Other conditions with pain - fracture etc
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26
Q

What are the symptoms of autonomic dysreflexia?

A

Pounding headache
Feeling of doom/anxiety
Profuse sweating
Chest tightness

Flushing above level of lesions
Pupillary dilatation
Cardiac dysrhythmias
Hypertension and bradycardia

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27
Q

What is the treatment of autonomic dysreflexia?

A
Get patient to sit - to reduce BP
Sublingual nifedipine 10mg
Sublingual GTN
Monitor BP every five mins
Remove precipitating cause
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28
Q

What is post-traumatic amnesia?

A

Inability to lay down new memories and retain information after traumatic brain injury

Variable duration - may be mins/months

Commonly anterograde amnesia :
Declarative - facts, association
Procedural - motor skis
Biographical - complex every day events

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29
Q

How is post traumatic amnesia managed?

A

Low stimulus environment
Reassurance, reorientation
Visual clues
Sedate only if essential for safety of patient or others

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30
Q

What is frontal lobe syndrome?

A

Impairment of executive function:
Difficulty planning
Personality changes
Perseveration

Response inhibition:
Disinhibition
Sexual disinhibition
Emotional lability

31
Q

What is involved in behavioural modification?

A

Monitoring behaviour:
Identify precipitating factors, behaviour and positive reinforcements

Modifying behaviour:
Positive reinforcement, time out, specialist neurobehavioural rehab units

Vocational rehabilitation:
Identify alternative work/educational options, planned withdrawal from work

32
Q

What are problems that may complicate a return to work in traumatic brain injury?

A

Cognition: poor concentration, memory, executive function

Behaviour: impaired judgements, disinhibition, aggression

Post concussive symptoms: fatigue, headache

Epilepsy: driving, work on scaffolding etc

Mental health problems: anxiety, depression, loss of confidence

33
Q

Can patients with head injury drive?

A

Significant head injury: banned from driving for 6-12 months

Epilepsy: barred from driving for 1 year post last seizure

Must have satisfactory clinical recovery, no visual field or cognitive impairments

34
Q

What is an initial prostheses?

A

A generic, adjustable prosthetic limb given after amputation of the lower limb

Assesses patients ability to walk

Improves unsteadiness, promotes exercise

Reduces post op swelling and promotes healing

35
Q

How is a prostheses made?

A

Cast made of residual limb

Positive made of cast to replicate size and shape of patients limb

Socket made which fits patients limb to enable weight bearing

Attach joints and shafts to make prosthesis the same length as patients leg

Prosthesis may have cosmetic cover or remain with the components exposed

36
Q

What are the contraindications to having a prosthetic fitted?

A

Angina - prosthesis increases energy costs of walking by 20%

Small/painful residual limbs - do not allow prosthetic fitting

Instead, use a wheelchair and sliding board for transfer

37
Q

What is phantom limb pain?

A

Pain located in the part of the limb that has been removed

Contributing factors include peripheral and central sensitisation leading to cortical reorganisation of bodies schema

Influences by stress, depression and anxiety

May result from neuroma - benign tumour of transacted nerve

38
Q

How is phantom limb pain managed?

A

Pain gradually improves with time - usually gone after a year

Amitriptyline is first line

Massage, hot/cold packs, tens machine

Neuroma - treat worth surgical excision or ablation by phenol injection

39
Q

What are the appropriate investigations for seizures?

A

EEG - only to support clinical diagnosis of epilepsy

MRI - to identify structural abnormalities that might cause epilepsy

Bloods - glucose, calcium, UandEs, LFTs

12 lead ECG - to assess for cardiogenic causes

40
Q

What is double support?

A

When part of each foot is in contact with the ground at the same time

This period is about 20% of the gait cycle

41
Q

What are the main components of the stance phase?

A

Initial contact:
Hip flexed, knee slightly flexed, ankle dorsiflexed

Loading response:
The above movements continue as leg decelerated to foot on ground

Mid stance:
Hip goes from Flexion to dorsiflexion
Knee from Flexion to extension
Ankle dorsiflexes

Preswing:
Hip is neutral
Knee flexes
Ankle plantar flexes and heel lifts off ground

42
Q

What are the main components of the swing phase?

A

Initial swing:
Hip and knee flex
Ankle dorsiflexes
To rapidly shorten limb so toes don’t touch ground

Terminal swing:
Leg prepares for initial contact of heel
Rapid hip Flexion
Knee extension

43
Q

How much of the gait cycle is stance?

A

60%

44
Q

How much of the gait cycle is swing?

A

40%

45
Q

What factors may cause dysfunction in the stance phase?

A

Limb instability
Trunk instability
Abnormal base of support

46
Q

What can cause weakness in knee extension resulting in limb instability?

A

Central/peripheral neurological conditions:
Polio
L2/L3 duac lesions
Femoral nerve lesions

47
Q

What compensatory measures may be taken to reduce weakness in knee extension?

A

Patient may use ipsilateral upper limb to knock knee back in ace during mid stance

Patient may allow knee hyper extension - this is painful!

Forward Flexion of the trunk

Initial contact with forefoot

48
Q

What is trendelenberg gait?

A

Pelvis drops in swing phase
Gluteus medius cannot maintain stability
Trunk compensates by flexing to ipsilateral side to shift centre of gravity over stance leg

Other compensatory strategies include extension of trunk at initial contact and arms placed behind centre of gravity

49
Q

What causes trendelenberg gait?

A

Reduced activity in gluteus medius causes trunk instability

Due to:
L5 root lesion
Damage to superior gluteal nerve
Direct muscle damage (THR)

50
Q

What is a stable base of support?

A

Base of support is created by feet as they contact with ground

Walking is stable when centre of gravity is within base of support

51
Q

What causes abnormal base of support?

A

When patients cannot put weight through their feet

Due to:
RA in joints of feet
Spasticity of gastrocnemius and soleus complex, Tibialis anterior and posterior - results in equinovarus foot

52
Q

What causes impaired limb clearance in swing phase?

A

Weakness of hip flexors, knee flexors or ankle dorsiflexors

Due to:
Neuro or muscle lesion to iliopsoas, hamstrings, Tibialis anterior

53
Q

What compensatory strategies may help in impaired Limb clearance?

A

Movement on to toes of contralateral limb during stance

Hip hitching - excessive hip and knee Flexion

Contralateral Flexion of trunk

Circumduction

54
Q

What does Varus mean?

A

Joint points out wards

55
Q

What does Valgus mean?

A

Joint points inwards

56
Q

What is equinovalgus?

A

Foot deformity in which weight is borne on the medial edge of the foot

May be seen in cerebral palsy

57
Q

What is equinovarus?

A

Foot deformity in which weight is borne on the lateral edge of the foot

Due to cerebral palsy, DMD, spasticity of Tibialis posterior anterior, gastrocsoleus etc

58
Q

What causes impaired limb clearance in swing phase?

A

Weakness of hip flexors, knee flexors or ankle dorsiflexors

Due to:
Neuro or muscle lesion to iliopsoas, hamstrings, Tibialis anterior

59
Q

What compensatory strategies may help in impaired Limb clearance?

A

Movement on to toes of contralateral limb during stance

Hip hitching - excessive hip and knee Flexion

Contralateral Flexion of trunk

Circumduction

60
Q

What does Varus mean?

A

Joint points out wards

61
Q

What does Valgus mean?

A

Joint points inwards

62
Q

What is equinovalgus?

A

Foot deformity in which weight is borne on the medial edge of the foot

May be seen in cerebral palsy

63
Q

What is equinovarus?

A

Foot deformity in which weight is borne on the lateral edge of the foot

Due to cerebral palsy, DMD, spasticity of Tibialis posterior anterior, gastrocsoleus etc

64
Q

How does a patient use a walking aid?

A

Walking aid eg sticks/crutch used to support the weaker leg

therefore weak leg is moved forward with the stick or both sticks and the strong leg takes the weight of the body

When two sticks and two weak legs, the leg moves forward with the contralateral stick

If two walking aids and one leg, move both forward at the same time, then swing weak leg through

65
Q

What is kinematic gait analysis?

A

Study of movement in space and time, regardless of forces generated

Performed with multiple cameras and reflection markers

Each side recorded with eight cameras and 15 markers

Temporal parameters recorded, including stride length, cadence, walking speed

66
Q

What is kinetic gait analysis?

A

Study of forces in the body that produce movement

Based on Newton’s third law, and requires 3d force sats from a force plate set on the floor

67
Q

What is hemiplegic gait?

A

Affects one side of the body - usually seen in UMN lesion

Associated reaction - shoulder adducted, elbow flexes, wrist pronated

Leg extended and internally rotated

Leg circumspection to compensate for lack of knee Flexion

68
Q

What is choreiform gait?

A

Wide based gait with slow leg raising and simultaneous knee Flexion

‘Flinging’ movements of legs

Associated with choreathetoid movements of upper limbs

Causes:
Huntington’s chorea
Dopaminergic medication

69
Q

What is scissor gait (spastic diplegia)

A

Spastic cerebral palsy - usually diplegic and paraplegic

Legs flexed slightly at hips and knees, giving crouching appearance

Knees and thighs hit or cross each other

Individual walks on tip toe

Ankles plantar flexes and internally rotated

Shoulders adducted and elbows flexed

Weak back and hip extensors, so shift centre of gravity posteriorly

70
Q

What is Parkinsonism gait?

A

Short steps

Reduced arm swing

Stooped posture

Centre of gravity ahead or behind feet

Fearination - hasty but short steps, attempting to compensate for displaced COG

Postural instability - difficulty standing from sitting

71
Q

What is ataxic gait?

A

Indicates cerebellar disease

Broad based gait
Lurching quality
Difficulty with turning
Difficulty walking in a straight line

72
Q

What is antalgic gait?

A

To avoid acute pain

Limited joint range of motion
Inability to bear weight in affected extremity

Stance phase duration shortened to compensate pain in affected leg

Resultant limp with slow and short steps

73
Q

What is foot drop?

A

Inability to dorsiflex ankle

Commonly due to peroneal palsy

Exaggerated hip and knee Flexion to compensate

74
Q

What is myopathic gait?

A

Weakness of proximal muscles causes ‘waddling gait’

Non weight bearing hip drops, and trunk shifts to love COG to contralateral side

75
Q

What is stomping/stamping gait?

A

When a patient has trouble with proprioception and cannot feel when foot reaches floor

Step transmit vibrations which are detected in the trunk