17 terms

10 central nervous system disorder Patho 2 winter 2016

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CNS Sensory Disorders

Tabes Dorsalis (Locomotor Ataxia)
involves a progressive degeneration of posterior grey matter of the cord and sometimes posterior root ganglia and posterior columns.
CNS Motor Disorders
Poliomyelitis

-an acute viral infection that eventually specifically targets the anterior horn cells of the cord, and the cranial nerve nuclei of the brain stem (lower motor neuron cell bodies). The result is flaccid paralysis.


Cerebral Palsy (CP)

-a loose term applied to a number of nonprogressive motor disorders resulting from CNS damage occurring before birth, at birth, or within the first 2-5 years, which results in an impairment of voluntary movement.


Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig's Disease)

-motor disorder involving progressive degeneration of corticospinal tracts, anterior horn cells, and/or bulbar motor nuclei.


Parkinson's Disease

-a slowly progressive neurodegenerative disorder of the CNS with four characteristic features:
CNS Disorders of Sensory and Motor Components
Multiple Sclerosis ( Disseminated Sclerosis, MS)

-chronic disease of the CNS, in which there is destruction of myelin and nerve axons. It begins as scattered patches of inflammation in the CNS white matter, and ends with degeneration of those myelin sheathes.

Traumatic Injuries of Brain and Spinal Cord

-cause bruising and swelling, and/or laceration and hemorrhaging. In the brain this is evidenced by changes such as altered consciousness, headache, and loss of equilibrium.
Headaches
Muscle Tension Headache (fibrositic headache)

-Pain associated with the head and face due to muscular contraction and psychological stress.

Cluster Headache

-unilateral vascular headache of short duration that reoccurs for short periods of time.

Migraine Headache

:-Excruciating headache often accompanied by nausea, vomiting, blurred vision, and hypersensitivity to stimuli.
Cognitive Disorders
Alzheimer's Disease

-chronic and progressive disease of cognitive functioning that makes up 60% of all dementia.

Epilepsy/Seizures:

-seizure disorder caused by neurological damage that is irreversible.
-are abnormal repetitive electrical discharges in the brain.
...
Etiology: Used to be usually syphilis. More currently, most cases are due to toxin exposure or part of the neurological manifestation in HIV/AIDS. Signs and Symptoms: The lesions in tabes dorsalis result in pain, ataxia, sensory changes and loss of
tendon reflexes. The onset is slow and insidious. The first and most characteristic symptom usually
is an intense, stabbing pain (lightning pain) in the legs. Later unsteadiness of gait
develops (ataxic gait). Other signs are general ataxia, hyperesthesia and paraesthesia, anesthesia, positive
Romberg's sign, and muscle atonia. Treatment: Medical treatment addresses the underlying cause. Massage may be used if no infection is present. Avoid deep work due to the sensory disturbances. No heat or cold applications
should be used.
CNS Motor Disorders

A. Poliomyelitis
(Polio; Infantile Paralysis; Acute Anterior Poliomyelitis)
Incidence: Polio occurs primarily in children and is now rare in the western developed countries. It is still found in underdeveloped countries. In the 1930's to the early 1950's, polio was pandemic and was the largest recent epidemic with the highest mortality rate, until the advent of AIDS.

Etiology and Pathogenesis:
There are many strains of the poliovirus, only some of which cause paralysis.
The poliovirus enters the mouth and subsequently enters the digestive system,
lymphoid tissues, blood, and eventually the nervous system where it shows selective affinity. The virus is highly contagious and before vaccinations were used, produced worldwide epidemics. Eventually the virus invades the lower motor neurons of the spinal cord and brain stem.
Damage by the virus to the lower motor neurons is the primary event, exciting an
intense inflammatory reaction and loss of the anterior horn cells. There are mild cases and severe cases depending upon the extent of infection and inflammation.
Signs and Symptoms: The polio virus causes a wide range of manifestations, including nonspecific minor illness of fever, malaise, and headache, lasting 1-3 days, or else a major illness with systemic symptoms of fever, headache, muscle pain and spasm progressing to flaccid paralysis. The distribution of the paralysis varies according to which segments of the cord are
involved. Given the random distribution of affected neurons the paralysis is
asymmetrical. If the anterior horns of the phrenic nerve are damaged, respiratory failure may occur. Restoration of function may be due to neurons not being completely destroyed or
reinnervation by collateral axons sprouting from surviving neurons and forming large
motor units for that muscle.
Treatment:
Massage treatment is given after the end of the acute infection and follows the
treatment guidelines for flaccid paralysis. Massage therapy may continue during convalescence and after recovery for lasting paralysis. It is not likely that you will treat anyone who has suffered from a recent bout of acute poliomyelitis.
POST-POLIO SYNDROME:
This occurs 30-40 years after the initial attack, and usually found in people over 50 who had polio in their childhood. There is a further loss of anterior horn motor neurons from an inflammatory response thought to be generated by latent infection.
The syndrome occurs only in those who had the paralytic form of polio. There are 1.5 million survivors of polio in the United States. Up to 2/3 will develop post-polio syndrome. It is more common in people who had severe paralytic polio and who were older at the time of the initial infection.
Signs and symptoms include:
A. Muscle fatigue and pain B. Decreased endurance C. Fasciculations D. Progressive weakness E. Atrophy in muscles originally affected by disease F. Joint pain G. Loss of movement H. Disruptions in ADL
Treatment: rest; massage to improve circulation; gentle stretches. Follow the guidelines for flaccid paralysis
Cerebral Palsy (CP)
Cerebral Palsy (CP)
Cerebral Palsy is a loose term applied to a number of nonprogressive motor disorders resulting from CNS damage occurring before birth, at birth, or within the first 2-5 years, which results in an impairment of voluntary movement.
There are numerous CP syndromes, but by far the most common (70% of cases) results in spastic paralysis. The spasticity is due to upper motor neuron involvement and patients may be mildly or severely affected.
Mental retardation is not part of the definition of cerebral palsy, although a patient with CP may also be retarded. However, it should not be assumed that persons with CP have any less intelligence because of their motor paralysis.
Incidence:
-affects 1-2 of every 1,000 infants -more common in premature infants
Causes:
-prematurity -in utero disorders (e.g. infection or trauma during pregnancy) -birth trauma -perinatal asphyxia -CNS trauma
Signs and Symptoms: can be mild to severe
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1. Main form is spastic (70% of patients). Spasticity presents in quadri, para, hemi,
or diplegia patterns. 2. Can also have athetoid (snake like, writhing) movements and ataxia 3. Affected limbs are poorly developed, stiff and weak.
Treatment: massage treatment for cerebral palsy is spastic paralysis treatment.
Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig's Disease)

CNS Motor Disorders
Etiology: Idiopathic.
Signs and Symptoms:
Early:
-40% begin with lower motor disturbance in hands - there is muscular weakness and atrophy - the progression is asymmetric - muscle cramps are common and may precede weakness
Later: upper motor neurons become involved and there are i. fasciculations
ii. spasticity iii. hyperactive deep tendon reflexes iv. dysarthria (difficulty speaking clearly) v. dysphagia (difficulty swallowing)
Eventually, ALS may affect the diaphragm, increasing chances of respiratory infections and necessitating use of a respirator.
The general and special senses, intellect, and voluntary eye movements, are not involved.
Prognosis: 50% of patients die within first 3 years
20% live 5 years 10% live 10 years Occasionally, a patient will survive as long as 30 years.
Treatment: Massage to decrease spasticity, PROM to the joints, attention to deformities and contractures.
Parkinson's Disease

CNS Motor Disorders
1. tremor at rest 2. sluggish intention of movements (poverty of movement) 3. muscle rigidity 4. postural instability
Incidence: 1 in 250 people over age 40; 1 in 100 over 65
Etiology: While the cause is idiopathic, there is a loss of the neurons in the substantia nigra of the basal ganglia and midbrain, which release dopamine.
Secondary Parkinsonism may be caused by encephalitis, trauma, carbon monoxide poisoning, and infarction in the midbrain.
Pathophysiology: The loss of dopamine leads to loss of inhibition from the basal ganglia. This loss of inhibition leads to unchecked excitation from areas that control movements.
Signs and symptoms:
1. The condition begins insidiously with a resting pill-rolling tremor of one hand. The tremor is maximal at rest, lessens with movement, and disappears while sleeping. It is enhanced by emotional tension or fatigue. The hands, arms, and legs usually are most affected, in that order. Many patients display only rigidity and never manifest tremor.
2. Reflexes and strength are often normal.
3. Hypertonia and progressive rigidity
4. Slowness and poverty of movement (bradykinesia), and difficulty in initiating movement.
5. Rigidity and hypokinesia may contribute to muscular aches and sensations of fatigue.
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6. The face has a blank expression and is mask-like (Parkinson's mask) and open- mouthed, with diminished blinking. Patient may drool, or choke.
7. Posture becomes stooped.
8. Patients find it difficult to start walking; the gait becomes shuffling with short steps, and the arms are held flexed to the waist and fail to swing with the stride. The steps may inadvertently quicken and the patient may break into a run to keep from falling. This is a festinating gait (festination).
9. A loss of balance and tendency to fall forward or backward when the center of gravity is displaced results from the loss of postural reflexes.
Note: most symptoms appear together in what is known as Parkinson's syndrome: tremor, hypertonus, rigidity, blank face, festination. [There is also loss of balance, frequent falling, and poverty of movement.]
Massage Treatment: Full body massage to try to lessen rigidity. Lots of PROM and gentle stretching Medical : Medications such as levadopa (carbidopa) which can produce side effects of
athetosis, involuntary movements of tongue and lips, head bobbing, grimacing Stem cell transplants, DBS, laser surgery
CNS Disorders of Sensory and Motor Components

A. Multiple Sclerosis ( Disseminated Sclerosis, MS)
Etiology: MS is idiopathic and listed as an autoimmune disease. Incidence:
Women get MS more than men. Age of onset: 20 - 40 years.
Disease course:
MS is a slowly progressive CNS disease. Its course highly varied and unpredictable with remissions and persistently recurring exacerbations.
MS begins as scattered patches of inflammation on the white matter causing patches of demyelination and formation of scar tissue (fibrous gliosis) called plaque. Thus, degeneration of the myelin sheath occurs due to destruction of the oligodendroglia. This results in disruption of normal neuronal transmission.
There is a predilection for the lateral and posterior columns, and optic tracts.
Life span in most cases is of normal length, and the average duration of illness probably exceeds 25 years but variability is great. Some patients have frequent attacks and are rapidly incapacitated.
Signs and symptoms: Because of the scattered nature of plaque formations, there is a diversity and multiplicity of neurological signs and symptoms in both motor and sensory systems. Cognitive and limbic areas can also be affected. The disease can present with varied mental, affective, motor (somatic and autonomic), and sensory signs and symptoms.
Early in the disease course:
tingling and numbness in arms, legs, trunk, and face visual disturbances: double vision (diplopia); partial blindness weakness and clumsiness in leg or hand stiffness and fatigability of limbs minor gait disturbances vertigo difficulty with bladder control mild emotional disturbances
Late in the disease course:
mental symptoms: apathy, dementia, depression, mania, inattention. motor symptoms: hyperreflexia, tremor, spasticity, ataxia, contracture and
paralysis sensory: hypoesthesia, numbness, paraesthesia, burning and shooting pain autonomic: urinary and defecatory problems
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IMPORTANT NOTE: Excess heat may accentuate symptoms and signs.
Treatment:
Medical: Drugs; attention to stress. Psychosocial support.
Massage: Full body massage with focus on spasticity. Increase ROM of joints and address contractures and deformity if present. Watch for decubitus ulcers.
"Massage and passive movement of weakened spastic limbs make patients more comfortable." -Merck Manual
Muscle Tension Headache (fibrositic headache)
Pain associated with the head and face due to muscular contraction and psychological stress.
Etiology: anything leading to muscle contraction. Trigger point referral. Joint irritation of cervical spine, TMJ, atlanto-occipital joint. Muscle spasm. Adhesions. Postural stress. Stress
Signs and symptoms:
1. Dull persistent ache. 2. Tightness around head, temple, forehead, occiput. 3. Pain typically increases in evening.
Treatment:
1. Massage during headache:
a. Reduce tone of thoracic muscles (upper traps, levator,
b. Drainage and circulatory work to same.
a. Same as above but more vigorous. b. Suboccipital, cervical, cranial and facial muscle work. c. Trigger point work. d. Postural work (upper cross & forward head postures could
e. Heat applications and stretches
rhomboids, thoracic erectors.
2. Massage between headaches:
contribute to tension).
Cluster Headache
A unilateral vascular headache of short duration that reoccurs for short periods of time. Massage Treatment: same as for tension headache.
Migraine Headache
D.
Excruciating headache often accompanied by nausea, vomiting, blurred vision, and hypersensitivity to stimuli.
Etiology: Idiopathic. May be a family history, hormonal or food triggers Signs and symptoms:
1. aura (prodromal symptoms) changes in mood.
anorexia. scintillating scotomas (seeing zigzags of light). pallor nausea double vision, flashing lights, dark spots
2. migraine pain can occur without aura. 3. photosensitivity 4. vomiting 5. diarrhea 6. sweating
Treatment: Medical: numerous drug therapies Massage: During headache, massage is usually not tolerable Between headaches:
deeper work to address trigger points, postural deviations
craniosacral work
acupuncture
Cognitive Disorders
A. Alzheimer's Disease
Alzheimer's Disease is a chronic and progressive disease of cognitive functioning that makes up 60% of all dementia. The disease is characterized by plaque build up in the brain, tangles of neurons, and atrophy of the cerebrum. There is also a change in neurotransmitter levels including a drop in ACh. Etiology: Multi-factoral including: some genetic risk factor, head trauma, aluminum toxins, viruses, and immunological factors. Incidence: Older people with a history of etiologic factors above. Signs and symptoms: This progressive disease is broken into three stages- Stage I - mild memory loss that progresses to Stage II - speech and language problems, personality changes, anxiety, delusions, depression, restlessness, sleeplessness, social withdrawal and deterioration of intellectual functions, which progresses to Stage III -terminal stage where the patient must rely on others for ADL. (Seizures, hallucinations, paranoia, delusions, or depression may occur in both stages II or III.) Massage: Massage will not reverse the process of Alzheimer's disease, but will do no harm as long as the client is comfortable. Therefore, with medical clearance, and within the comfort levels of the client, massage may be given.
Epilepsy/Seizures:
Seizures are abnormal repetitive electrical discharges in the brain. Seizures may result from:
traumatic brain injury
poisons (i.e. some venoms, or alcohol poisoning)
metabolic imbalances (hypoglycemia and hypercalcemia)
epilepsy.
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Seizures may take different forms for different people; they range from barely noticeable to life threatening.
Epilepsy is a seizure disorder caused by neurological damage that is irreversible.
Types of Seizures: Generalized Seizures - result from discharges in both cerebral hemispheres.
These are sometimes referred to as petit mal and grand mal seizures. Petit mal
seizures are characterized by brief interruptions in awareness and activity. Grand
mal or tonic-clonic seizures are characterized by contraction of muscles resulting in
violent movements of the extremities, loss of consciousness, bowel and bladder
incontinence, ending in bilateral rhythmic contraction of the limbs. Status Epilepticus - this is a medical emergency where the seizure does not stop,
or many seizures occur in rapid succession without the client regaining
consciousness.
Massage for the client with seizure disorder:
When treating a client with epilepsy, the massage therapist needs to be familiar with the type, triggers, and duration of the client's seizures. Note that massage for an epileptic client is not for their epilepsy but instead for their chief complaint or concern.
A contingency plan or protocol should be in place should the client have a seizure during the session. This needs to be established before beginning the treatment. Aura or prodromal symptoms may precede a seizure. The client and therapist should establish a hand signal or other way the client can signal the therapist should the client feel a seizure coming on.
The therapist should also take extra precautions not to trigger a seizure. Flashing lights, certain patterns on walls or fabric, odors (such as scented oils or candles), lack of sleep, and changes in body chemistry (fasting, food allergies) are all possible triggers.
The therapist should give a relaxation-based massage, avoiding abrupt movements as well as deep, vigorous, or painful techniques.
Should the client experience a seizure during the session the therapist should not attempt to restrain them or place anything in their mouths. The therapist should stay with the client and try to protect them from bumping into anything in the room.
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If the seizure lasts longer than 10 minutes or if the client gets injured during the seizure, the client should go to the hospital. However, this is the client's choice to make if they are cognizant to do so.
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