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Chapter 3 - Part A Nervous System Conditions

Chapter 3 - Part A Nervous System Conditions

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Chapter 3 - Part A Nervous System Conditions

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  1. Chapter 3 - Part ANervous System Conditions • Introduction • Chronic Degenerative Disorders • Infectious Disorders • Psychiatric Disorders

  2. Chapter 3 - Part ANervous System Conditions: Introduction • Function: • Nerves are bundles of fibers that carry messages to and from the CNS (motor vs. sensory) • Structure: • Each neuron has a dendrite, cell body, and axon • Sensory neurons have long dendrites, cell bodies just outside the spine (dorsal root ganglia), short axons • Motor neurons have tiny dendrites, cell bodies in spinal cord; long axons to muscles or glands • Interneurons in spinal cord allow quick response to stimuli (reflex arc) (Fig. 3.1)

  3. Chapter 3 - Part ANervous System: Introduction, cont. • Long fibers in PNS have two layers: • Myelin (speeds transmission, insulates; also present in CNS) • Neurilemma (allows for regeneration; not present in CNS) (Fig. 3.2) • General neurologic problems: • Damage to peripheral nerves (good prognosis) • CNS damage (poorer prognosis, but maybe not as bleak as generally considered) • Psychiatric disorders

  4. Chronic Degenerative Disorders • Alzheimer’s Disease • Amyotrophic Lateral Sclerosis • Multiple Sclerosis • Parkinson’s Disease • Peripheral Neuropathy • Tremor

  5. Alzheimer’s Disease • Progressive degeneration of the brain, leading to memory loss, personality changes, and death • Incidence: • Affects 5% of the U.S. population (4.5 million); • 50% of people over 85 years old; • Estimated 16 million people by 2050

  6. Alzheimer’s Disease, cont. • Features: • Plaques: sticky deposits of beta amyloid trigger an inflammatory response • Neurofibrillary tangles: tau proteins degenerate, causing neurons to collapse and move out of relationship to each other • Low neurotransmitters: as neurons degenerate, less neurotransmitters are produced; fewer synapses are functional • Genetics: Some people are genetically predisposed, especially to the development of plaques

  7. Alzheimer’s Disease, cont. • Signs and symptoms (7 phases): 1. No impairment 2. Very mild decline (“pre Alzheimer’s”) 3. Mild dementia (some memory and word loss) 4. Moderate dementia (loss of some skills; social withdrawal) 5. Moderately severe dementia (assistance is needed for complex tasks) 6. Severe dementia (profound memory loss, personality changes, disorientation, loss of bladder/bowel control) 7. Very severe dementia (loss of language, muscle control)

  8. Alzheimer’s Disease, cont. • Diagnosis: • Not definitive until death • Mental tests, ruling out other causes • Differential diagnosis: • Vascular dementia • Stroke/TIA • Parkinson’s • Other

  9. Alzheimer’s Disease, cont. • Treatment: • Some drugs can slow progress, if caught early • Massage? • Touch is calming influence, even in advanced stages • Beware of other accumulated disorders, inability to communicate verbally • See Figs. 3.3a, 3.3b

  10. Amyotrophic Lateral Sclerosis • Progressive destruction of motor neurons in CNS and PNS • Lou Gehrig’s disease • Incidence: • 4,000 to 5,000 diagnoses per year, • Mostly 40–70 years old • Three types: • Sporadic (most common) • Familial • Mariana Island type

  11. Amyotrophic Lateral Sclerosis, cont. • Etiology (current theories): • Neural tangles and plaque (like Alzheimer’s, but only on motor neurons) • Glutamate accumulates and kills postsynaptic neurons • Free radical damage (especially for familial ALS)

  12. Amyotrophic Lateral Sclerosis, cont. • Signs and symptoms: • Stiffness, loss of coordination, usually starts distally and progresses toward the core • May become painful as muscles atrophy and the skeleton collapses • No impact on intellect • Diagnosis: • Rule out other similar presentations; no specific test

  13. Amyotrophic Lateral Sclerosis, cont. • Treatment: • Palliative • Some drugs may limit glutamate, prolong function • Prognosis: • Death within 2–10 years from pneumonia or renal infection • Some survive for decades (Stephen Hawking)

  14. Amyotrophic Lateral Sclerosis, cont. • Massage? • This is a motor dysfunction; sensation stays intact • Massage may help with pain related to degeneration • Work with health care team

  15. Multiple Sclerosis • Inflammation, degeneration of myelin sheath in CNS • Incidence: • Most common in people who live far from the equator; • Whites more than other groups • Women more than men (2:1) in youth; more or less equal among older; • Approximately 350,000 people in United States have MS; • Approximately 9,000 diagnoses per year

  16. Multiple Sclerosis, cont. • Myelin in CNS is attacked and replaced with scar tissue • Electrical insulation is lost; electrical impulses short-circuit • Probably autoimmune • Flare and remission • Inflammation damages myelin, and ultimately the nerve tissue as well

  17. Multiple Sclerosis, cont. • Signs and symptoms: • Weakness • Spasm • Changes in sensation (paresthesia, reduced sensation, numbness) • Optic neuritis • Urologic dysfunction • Sexual dysfunction • Difficulty walking • Loss of cognitive function • Depression • Lhermitte’s sign (electrical sensation when neck is in flexion) • Digestive disturbance • Fatigue

  18. Multiple Sclerosis, cont. • Progression: • Relapse/remitting (flare/remission) • Primary progressive (steady decline in function) • Benign MS (1 flare only) • Malignant MS (rapidly progressive)

  19. Multiple Sclerosis, cont. • Diagnosis: • Diagnostic criteria: • Objective evidence of at least two episodes • Episodes of flare are separated by at least one month and by location of affected function • No other explanation for symptoms can be found • Differential diagnosis is a long process; can take years

  20. Multiple Sclerosis, cont. • Treatment: • Symptomatic • Steroids, immune suppressants • Exercise, physical therapy for maintenance • Massage? • Most appropriate when in remission • MS patients have poor tolerance for rapid changes in temperature; avoid heat and cold (warm and cool are better) • Watch for accurate sensation; be conservative in numb areas

  21. Parkinson’s Disease • “Shaking palsy”: degeneration of motor center in brain • Incidence: • 1%–2% of people over 50; men more than women (3:2); 500,000 in United States; 50,000 diagnoses/year • Anatomy review: • Basal ganglia is one motor center deep in brain • Basal ganglia cells need dopamine • Dopamine is manufactured by nearby substantia nigra (“black stuff”)

  22. Parkinson’s Disease, cont. • Etiology: • Substantia nigra dies off; insufficient dopamine to basal ganglia; loss of motor function • Causes: • Mostly unknown • Environmental exposures? • Pugilistic parkinsonism (repeated head trauma) • Premature death of substantia nigra cells

  23. Parkinson’s Disease, cont. • Signs and symptoms (Fig. 3.4): • Primary: • Nonspecific pain, fatigue • Resting tremor • Bradykinesia (difficulty initiating movement) • Rigidity (especially of trunk flexors, facial muscles) • Poor postural reflexes

  24. Parkinson’s Disease, cont. • Signs and symptoms: • Secondary: • Shuffling gait (festinating gait: loss of center of gravity) • Changes in speech • Changes in handwriting (“micrographia”) • Sleep disorders • Depression • Mental degeneration (unclear whether part of disease, or part of medication side effects)

  25. Parkinson’s Disease, cont. • Treatment: • Supplementing dopamine is problematic • Blood-brain barrier • Resistance • Different activity in different places in the brain • Deep brain stimulation • Surgery to alter thalamus, other structures • Physical, speech, occupational therapy

  26. Parkinson’s Disease, cont. • Massage? • May be appropriate, helpful with muscle stiffness and quality of life issues • Clients have trouble with tables • Elderly clients may have other conditions as well • Rigidity is safer for massage than spasticity

  27. Peripheral Neuropathy • A complication of other pathologic conditions leading to peripheral nerve damage • Mononeuropathy/polyneuropathy • Possible causes: • Alcoholism • Vitamin deficiency • Toxic exposure • HIV/AIDS • Lupus • Scleroderma • Rheumatoid arthritis • Mechanical pressure related to carpal tunnel syndrome, disc disease, thoracic outlet syndrome, etc…

  28. Peripheral Neuropathy, cont. • Signs and symptoms: • Usually slow onset, often in hands or feet • Hypersensitivity, often followed by numbness • Motor neuron damage can lead to specific muscle weakness • Treatment: • Depends on cause • Pain relievers, topical applications, TENS units, biofeedback, acupuncture, relaxation techniques, massage…

  29. Peripheral Neuropathy, cont. • Massage? • Depends on cause, client • Numbness is always a caution! • May exacerbate or soothe hypersensitivity

  30. Tremor • Rhythmic oscillation of antagonistic muscles in a fixed plane • Classes of tremor • Resting tremor • Postural tremor (occurs when holding a limb up against gravity: arm in flexion) • Kinetic tremor (occurs in large muscle groups for general movement) • Activity-specific (occurs in hands for fine-motor control) • Psychogenic (disappears when patient is distracted)

  31. Tremor, cont. • Further classifications: • Physiologic (worse with stress, fear, etc.) • Pathologic (idiopathic or related to underlying disorder) • Types of tremor: • Essential tremor (most common diagnosis) • Slowly progressive, usually appears around age 45 • Huntington’s disease • Hereditary degeneration of neural tissue • Parkinson’s disease • Degeneration of substantia nigra and loss of basal ganglia • Others • More rare causes for tremor

  32. Tremor, cont. • Treatment: • Depends on cause; can include… • Dopamine precursors, Botox, beta blockers, anti-seizure medications… • Surgery at globus pallidus or thalamus • Massage? • Often useful, but should be diagnosed for cause • Work with health care team for best results

  33. Infectious Disorders • Encephalitis • Herpes Zoster • Meningitis • Polio, Postpolio Syndrome

  34. Encephalitis • CNS infection, usually viral • Used to be endemic to certain areas; now many are worldwide • Incidence: • Relatively rare, even with West Nile Virus: <5,000 infections/year

  35. Encephalitis, cont. • Etiology: • Usually vector-borne (mosquitoes, some ticks) • Viral attack on brain, sometimes spinal cord • Infants, elderly, immune-suppressed are most vulnerable • Signs and symptoms: • Mild to life-threatening • Fever, headache, irritability, stupor, coma; can cause personality and memory changes

  36. Encephalitis, cont. • Treatment: • “Supportive therapy”: antivirals and good care • Massage? • Fever, especially with headache, contraindicates massage • Clients with a history of encephalitis may be safe; get information about any permanent loss of function

  37. West Nile Virus • August, 1999: 6 people in Queens, NY go to the hospital with high fever and headache • In nearby boroughs, birds were dying and horses were getting sick • At end of season, 56 cases of WNV were confirmed among humans; 7 deaths (all people older than 68 years) • 2002: 4,000+ confirmed cases; 284 deaths • Most develop flu-like symptoms; 1:150 develop neurologic symptoms

  38. Herpes Zoster • Viral attack on sensory dendrites in skin • Also called “shingles” • Incidence: Approximately 300,000 /year • Etiology: • Causative agent is Varicella zoster (same as chicken pox) • Member of the herpes family; never fully expelled • Virus is dormant in dorsal root ganglia until a drop in immune function; then it resurfaces as shingles along the affected dermatome • Triggers include stress, age, immune suppression, or other infections

  39. Herpes Zoster, cont. • Signs and symptoms: • Painful blisters on a red base • Unilateral on affected dermatome • Trunk and buttocks are most frequent (Fig. 3.5) • Can affect the face through trigeminal nerve • Complications: • Secondary bacterial infection of blisters • Damage to trigeminal nerve: Ramsey-Hunt syndrome • Postherpetic neuralgia

  40. Herpes Zoster, cont. • Treatment: • Antiviral medication, topical anesthetics, anti-inflammatories, painkillers • Massage? • Active shingles is extremely painful! • Communicability is an issue if the massage therapist has no history of chicken pox or chicken pox vaccine • During recovery, be guided by tolerance of the client

  41. Meningitis • Inflammation of meninges (pia and arachnoid) • Incidence: • Mostly children < 5 years old; • About 300 deaths/year; • Very young, very old, and immune suppressed are most vulnerable • Can be bacterial or viral • Bacterial: Streptococcus pneumoniae or Neisseria meningitides; more severe infections with a high risk of permanent damage; responsive to antibiotics • Viral: many agents, including herpes simplex; lower risk of long-term damage

  42. Meningitis, cont. • Signs and symptoms: • High fever and chills • Deep red or purple rash • Extreme headache • Aversion to bright light • Stiff, painful neck • More extreme: • Drowsiness, slurred speech, nausea, vomiting, delirium, convulsions, coma

  43. Meningitis, cont. • Diagnosis: • Spinal tap (important to know the causative agent!) • Treatment: • Antibiotics for bacterial infection; supportive therapy for viral; prognosis is generally good • Communicability: • Mucous secretions (like cold or flu) • Not every exposed person develops symptoms (1:1000)

  44. Meningitis, cont. • Prevention: • Vaccine against Haemophilus influenzae (bacterial causative agent) • Vaccines against meningococci recommended for travelers • Massage? • Not appropriate during acute infection • Afterward, get information about permanent damage, if any

  45. Polio, Postpolio Syndrome • Polio: viral attack on motor neurons in spinal cord • Also called infantile paralysis • Postpolio Syndrome (PPS): progressive muscular weakness that may develop years or decades after polio infection • Incidence: • 300,000 polio survivors in the United States; • Approximately 25% have symptoms of PPS (overlap with arthritis and other orthopedic problems)

  46. Polio, Post Polio Syndrome, cont. • Polio etiology: • Virus enters through mouth, goes through GI tract and ends up in spinal cord • 1:100 people exposed develop symptoms • Practically extinct in the wild, especially in Western hemisphere • Affected motor neurons degenerate, leading to specific muscle weakness • Other motor nerves serving muscles in same groups may compensate (Fig. 3.6) • Usually in lumbar spine, can affect diaphragm, heart

  47. Polio, Post Polio Syndrome, cont. • Postpolio syndrome etiology: • Not a resurgence of original infection • Cumulative wear and tear leads to progressive muscle weakness later in life • Postpolio syndrome symptoms: • Sudden onset of new pattern of weakness, fatigue • Sleep, breathing, other difficulties • Cycles of degeneration and recovery

  48. Polio, Post Polio Syndrome, cont. • Treatment: • Motor dysfunction (not sensory): hydrotherapy and massage are safe and effective • Adjustments to supportive tools (crutches, braces, etc.) • Careful exercise to avoid over-stressing motor neurons and damaged muscles

  49. Polio, Post Polio Syndrome, cont. • Prevention: • Two effective vaccines • Need to be administered fully to avoid outbreaks of cultured virus • Polio survivors need to exercise carefully, emphasizing uninvolved muscles • Massage? • Because sensation is intact, massage is safe and appropriate • Work to improve nutrition, efficiency, function of damaged muscles

  50. Psychiatric Disorders • Attention Deficit Hyperactivity Disorder • Anxiety Disorders • Chemical Dependency • Depression • Eating Disorders