Professional Documents
Culture Documents
DATE: 03/21/2009
REVISION HISTORY
Diseases of the central and peripheral nervous system. This includes disorders of the brain, spinal
cord, cranial nerves, peripheral nerves, nerve roots, autonomic nervous system, neuromuscular
junction, and muscle.
Pict:1
The Central Nervous System (CNS) is exactly what the name implies. It is the "absolute" central -
nervous - system. All of the other nerves that feed off the central - nervous - system are peripheral
nerves. These peripheral nerves are part of the peripheral nervous system (PNS). For the purpose of
this site, I have separated the Central Nervous System from the Peripheral Nervous System.
The Central Nervous System is composed of the Brain and Spinal cord, along with their nerves and
end organs (the end of nerves) that control voluntary and involuntary acts. In other words, those
physical body processes that you do on your own (moving your arm) and those you do without having
to tell your body to do it (like breathing).
The parts of the brain governing consciousness and mental activities are; parts of the brain, spinal
cord, and their sensory and motor nerve fibres controlling skeletal muscles; and end organs of the
body wall. Your CNS is the Master Control Centre, the CEO, the Commander in Chief, the Big Kuhuna,
The Master Communicator and the Grand Pooh-Bah all rolled into one!
1.1.1 BRAIN:
The brain is a large soft mass of nerve tissue that is contained inside a vault of bone called the
cranium. It is the cranial portion of the CNS. The brain is also called the "encephalon." The
brain is composed of neurons (nerve cells) and neuralgia (supporting nerve cells). The brain
consists of gray and white matter. The gray matter is nervous tissues of a grayish color that
forms an "H" shaped structure and is surrounded by white matter.
Pict:2
The human brain has more than 10 billion nerve cells and over 50 billion other cells and now weighs on
an average of 3 1/8 pounds, where it used to weigh less than 3 pounds. The brain monitors and
regulates your unconscious bodily functions like breathing and heart rate, and coordinates most of your
voluntary movement. It is also the area of consciousness, thought and creativity!
Pict:3
The central nervous system, gives rise to the peripheral nervous system as shown in Pict:4 (the nerves
on the periphery of the body). The autonomic nervous system (ANS) is under control of central nervous
system and is also part of the peripheral nervous system, although these nerves stay within the body
and effect organs and soft tissues and do not leave to effect appendages (arms and legs). The
autonomic nervous system (ANS) is "automatic" and in control of involuntary bodily functions and it is
divided into two parts: The sympathetic and parasympathetic nervous system. It regulates the function
of glands, the adrenal medulla, smooth muscle tissue, organs and the heart.
Pict:4 Pict:5
The spinal cord is an ovoid column of nervous tissue that averages about 44 cm in length
when it is flattened out. The spinal cord extends from the medulla oblongata in the brain stem
to the 2nd lumbar vertebra in the spinal canal.
All of the nerves in your arms, legs and trunk originate from the spinal cord. The spinal cord
is the center of reflexive action. When you are stimulated in any way, shape or form, there is
a reflex arc that goes from the peripheral nerve to the spinal cord, up to the brain and back
down to relay the action. That's some pretty quick service from your CNS as shown in Pict:6.
Especially when you just about drop something and catch it quickly or if you are Andy
Roddick hitting a150 mph tennis ball at the 2004 Davis Cup.
Pict:6
Pict:6
The spinal cord is housed in a vertebral (bony) vault for its own protection. The spinal cord
travels down through a hole in each vertebrae. If you were to see the spinal cord in a cross-
section, you would notice that it does not fill the vertebral space in the vertebral column, it is
surrounded by other tissue (pia mater as shown in Pict:9), cerebrospinal fluid (CSF as shown
in Pict:8), another tissue (arachnoid mater as shown in Pict:9), and still another tissue (dura
mater as shown in Pict:9). The three types of mater are called the meninges. The meninges
also surround the brain. Hence the word "meningitis" when there is an inflammation of the
meninges or membranes of the spinal cord or brain.
Pict:8
Pict:9
Cerebrospinal fluid (CSF) when normal contains 50 - 75 mg of sugar per 100 ml. The sugar
content is lower than that of blood. The CSF is a water cushion protecting the brain and
spinal cord from physical impact.
The "H" shape from the gray matter inside the white matter in the brain is carried through the
spinal cord as well because they are attached to one another. The anterior "horn" of the "H"
is composed of motor cells from the fibers that make up the motor portions of the peripheral
nerves as shown in Pict:10. The sensory neurons as shown in Pict:11 enter the posterior
"horn" of the "H." Incidentally, the "H" does not mean "horn" although the "H" formation does
represent the anterior and posterior sides at which the nerves enter.
Pict:10
Sensory Neurons carry impulses away from the spinal cord and brain to muscles or glands
Pict:11
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2.1 DEFINITION:
Spinal cord trauma (Spinal cord injury; Compression of spinal cord) is damage to the spinal
cord. It may result from direct injury to the cord itself or indirectly from damage to surrounding
bones, tissues, or blood vessels.
2.2 CAUSES:
Spinal cord trauma can be caused by any number of injuries to the spine. They can result from
motor vehicle accidents, falls, sports injuries (particularly diving into shallow water), industrial
accidents, gunshot wounds, assault, and other causes.
A minor injury can cause spinal cord trauma if the spine is weakened (such as from rheumatoid
arthritis or osteoporosis) or if the spinal canal shown in Pict:12 protecting the spinal cord has
become too narrow (spinal stenosis shown in Pict:13) due to the normal aging process.
Pict:13
Direct injury, such as cuts, can occur to the spinal cord, particularly if the bones or the
disks have been damaged. Fragments of bone (for example, from broken vertebrae, which are
the spine bones) or fragments of metal (such as from a traffic accident) can cut or damage the
spinal cord.
Direct damage can also occur if the spinal cord is pulled, pressed sideways, or
compressed. This may occur if the head, neck, or back are twisted abnormally during an
accident or injury.
Bleeding, fluid accumulation, and swelling can occur inside the spinal cord or outside the
spinal cord (but within the spinal canal). The accumulation of blood or fluid can compress the
spinal cord and damage it.
Most spinal cord trauma happens to young, healthy individuals. Men ages 15-35 are most
commonly affected. The death rate tends to be higher in young children with spinal injuries.
Risk factors include participating in risky physical activities, not wearing protective gear
during work or play, or diving into shallow water.
Older people with weakened spines (from osteoporosis) may be more likely to have a
spinal cord injury. Patients who have other medical problems that make them prone to falling
from weakness or clumsiness (from stroke, for example) may also be more susceptible.
2.2 SYMPTOMS:
Symptoms vary somewhat depending on the location of the injury. Spinal cord injury causes
weakness and sensory loss at and below the point of the injury. The severity of symptoms
depends on whether the entire cord is severely injured (complete) or only partially injured
(incomplete).
The spinal cord doesn't go below the 1st lumbar vertebra, so injuries at and below this level do
not cause spinal cord injury. However, they may cause "cauda equina syndrome" injury to the
nerve roots in this area, shown in Pict:14.
Pict:14
When spinal cord injuries occur near the neck shown in Pict:15, symptoms can affect both the
arms and the legs:
Pict:15
When spinal injuries occur at chest level, symptoms can affect the legs:
Injuries to the cervical or high-thoracic spinal cord may also result in blood pressure problems,
abnormal sweating, and trouble maintaining normal body temperature.
Pict:16
When spinal injuries occur at the lower-back level, varying dgrees of symptoms can affect the
legs:
PICT:17
Loss of normal bowel and bladder control (may include constipation, incontinence,
bladder spasms)
Numbness
Pain
Sensory changes
Spasticity (increased muscle tone)
Weakness and paralysis
A CT scan or MRI of the spine may show the location and extent of the damage and
reveal problems such as blood clots (hematomas shown in Pict:18).
Myelogram (an x-ray of the spine after injection of dye shown in Pict:19) may be
necessary in rare cases.
Somatosensory shown in Pict:20 evoked potential (SSEP) testing or magnetic
stimulation may show if nerve signals can pass through the spinal cord.
Spine x-rays shown in Pict:21 may show fracture or damage to the bones of the spine.
Pict:18
Pict:19
Pict:20
Pict:21
Physical therapists are involved in many aspects of patient care following a spinal cord injury.
The major areas are as follows:
Respiratory Care
Range of Motion
Muscle Strengthening
Balance
Wheelchair Skills
Transfers
Skin Care
2.6.1.1 MANAGEMENT:
2. Mechanical ventilation.
Recognizing role of surfactant production
Positive-end expiratory pressure (PEEP)
Monitoring for pulmonary embolism and pulmonary effusion
Treatment of complications of short and long-term ventilation
Evaluation of the need for long-term ventilation
Physical therapists help to maintain or increase your joint range by stretching your muscles and
moving your joints. It is important to keep your joints mobile in order to increase your ability to
move and perform everyday functions. Range of motion can also help to decrease you pain.
Range of motion in joints is often impaired after injury, illness, or surgery. When range of
motion is lost, your physical therapist may use joint and soft tissue mobilization or
stretching exercises to restore more useful, full movement. See Pict:22 .
Joint and soft tissue mobilization is a unique, hands-on technique that allows the physical
therapist to release restrictions around joints and throughout the soft tissue system. By
releasing these restrictions your physical therapist works to achieve your full potential
range of motion in an area of dysfunction.
Stretching exercises help to restore length to soft tissue that has shortened and lost
elasticity. Your physical therapist may help you stretch specific areas and then teach you
a stretching program to continue at home. Physical therapists also teach stretching to
help prevent back problems and athletic injuries.
Pict:22
Movement depends on adequate muscle strength. Muscles may weaken from surgery,
injury, or simply from not being used. Physical therapists can help improve strength by
making muscles work harder through exercise and electrical stimulation.
Electrical stimulation may be used when muscles are immobilized (such as when
a limb is casted after surgery) or when muscles are extremely weak. To exercise
these muscles, an electrical impulse is sent through the skin causing muscles to
contract automatically
Following a spinal cord injury, it is very important for you to increase your strength in all muscles
that you still have control over. These muscles will have to work much harder than they did before
the injury in order to compensate for lost movements. Physical therapists can teach you the
correct exercises to increase the strength of specific muscles without causing injuries.
Many forms of exercise increase muscle strength. All involve progressively increased resistance.
When a muscle is very weak, movement against gravity alone is sufficient. As muscle strength
increases, resistance is gradually increased by using stretchy bands or weights. In this way,
muscle size (mass) and strength are increased, and endurance improves.
Pict:23
Pict:24
Pict:23
When people are ready for ambulation exercises, they may begin on parallel bars, then
progress to walking with mechanical aids, such as a walker, crutches, or a cane. Some
people need to wear an assistive belt, which the therapist uses to prevent them from
falling.
As soon as people can walk safely on a level surface, they may be taught how to step
over curbs or to climb stairs. When climbing up stairs, they are instructed to step up with
the unaffected leg first. To climb down stairs, they are instructed to step down with the
affected leg first. The phrase "good is up, bad is down" can help people remember.
Family members and caregivers who help people walk should learn how to support them
correctly.
Pict: 24
A large amount of people who have had a spinal cord injury will have to use a wheelchair at least
some of the time. Using a wheelchair allows you to get where you want to go as independently as
possible. In order to independently move your wheelchair, there are many skills that you have to
learn. These vary from simple skills such as maneuvering wheelchair safety to more complex
skills such as climbing curbs and ramps.
Pict: 25
2.11 TRANSFERS:
Depending on where your injury is, most spinal cord injured patients can learn to get in and out of
their bed and wheelchair independently. Physical therapists help teach you the easiest way for
you to transfer and move around.
For many people (particularly those who have had a hip fracture, an amputation, or a stroke),
transfer training is a critical goal of rehabilitation. Being able to transfer safely and independently
from bed to chair, chair to toilet, or chair to a standing position is essential to remaining at home.
People who cannot transfer without help usually require 24-hour assistance. Caregivers may help
them transfer using special devices, such as a gait belt or harness. See: Pict 26
Pict 26
The techniques used in transfer training depend on the following:
Whether people can bear weight on one or both legs
Whether they can balance well
Whether they are paralyzed on one side of the body
Assistive devices can sometimes help. For example, people who have difficulty standing from a
seated position may benefit from a seat-lifting chair or a chair with a raised seat. See: Pict 27
Pict 27
Tilt Table: see Pict 28 If people have been limited to strict bed rest for several weeks or have had
a spinal cord injury, they may get dizzy when they stand up (orthostatic hypotension—see Low
Blood Pressure: Orthostatic Hypotension). A tilt table may be used to help such people. This
procedure may retrain blood vessels to narrow (constrict) and widen (dilate) appropriately in
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response to changes in posture. People lie face up on a padded table with a footboard and are
held in place with a safety belt. The table is tilted very slowly, determined by how well people
tolerate it, until they are nearly upright. The slow change in posture enables the blood vessels to
regain the ability to constrict. How long the upright position is maintained depends on how well
people tolerate it, but it should not exceed 45 minutes. The tilt-table procedure is done once or
twice a day. Its effectiveness varies depending on the type and degree of disability.
Pict 28
a. The most important initial indicator of the severity of a head injury is the patient's level of
consciousness. A competent observer should assess the patient's consciousness level as soon as
possible after the injury has occurred. A severe head injury may be defined as one that leaves the
patient unconscious for at least 6 hours. A patient who has an altered level of consciousness less
severe and for a shorter time period may have medical problems much later, problems caused by
the injury.) Therefore, a patient with any level of impaired consciousness after a head injury should
be treated as though he has a serious head injury. See Pict 29.
b. The majority of head injuries are mild and self-limiting. However, since severe head injuries can be
life-threatening, it is important to assess and treat a head injury correctly to prevent death or
disability from secondary brain damage.
Pict: 29
3.1 PATHOPHYSIOLOGY:
Pathophysiology is the physiology of disordered function. When there is trauma to the central
nervous system in the form of a head injury, a variety of pathophysiological responses can
occur.
Pict:30
Pict:30
Increased blood volume due to vasodilation and increased cerebral blood flow
to the injured areas.
Buildup of extra blood volume putting pressure on the brain and decreasing
blood flow to the injured part.
NOTE: Since the edema builds over a period of 24 to 48 hours, early care and efforts
to decrease the vasodilation is important.
b. Carbon dioxide may build up, having a critical effect on cerebral vessels. This
buildup causes more vasodilation.
NOTE:
Hyperventilation -- a condition marked by fast, deep breathing, which tends to remove increased amounts of
carbon dioxide from the body and lower the partial pressure of the gas, causing buzzing in the ears, and
tingling of the lips and fingers. See picture 31
Pict. 31
d. Unconsciousness may occur due to injury to the cerebral cortex or the brain stem. See picture 32.
Pict. 32.
e. If there is increased intracranial pressure (ICP) and decreasing cerebral blood flow, no matter what
the cause, the level of consciousness is depressed.
f. The intracranial cavity is filled to capacity with contents that cannot be compressed
-- cerebral spinal fluid, intravascular blood, brain tissue water (interstitial fluid). If
the volume of one of the constituents of the intracranial cavity increases, a
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reciprocal decrease in volume of one or both of the others must occur. Otherwise,
the result is an increase in intracranial pressure.
Pict:33
A patient with head injury may experience an alteration in his level of consciousness.
Other symptoms associated with a severe head injury may include convulsions,
delirium, coma, paralysis, and increased intracranial pressure, which will be discussed
here. The skull (a container that cannot expand) holds the brain, vascular tissue, and
cerebrospinal fluid. Any problem (trauma, edema, tumor, infection, or bleeding) which
adds to the contents of the skull will result in an increase in intracranial pressure in the
skull. That increased pressure sets off the changes listed below:
a. As the intracranial pressure increases, the blood vessels are squeezed from the
outside, restricting blood flow throughout the arteries.
b. As the brain notes a drop in blood pressure, the sympathetic defenses respond,
causing the blood pressure to increase.
c. Respiratory changes occur due to the chemoreceptors that sense changes in the
blood chemistry.
d. The vagus nerve is affected, causing the pulse to slow.
e. Cushing's response - Increased blood pressure characterized by slow pulse. This
is a clear but late sign of increased intracranial pressure.
f. As the intracranial pressure progresses, the level of consciousness is altered.
Eventually, unconsciousness occurs because the body's vital functions cannot
operate properly. Ultimately, there is brain death due to loss of adequate cerebral
perfusion (passage of fluid through the brain).
g. Once the brain's ability to compensate is exhausted, the areas of the brain shift,
causing herniation.
NOTE: Compression may be from above (central syndrome) or from the side (lateral
syndrome). The central syndrome progresses in a more orderly manner and causes
unconsciousness early.
Pict:34
Pict:35
Pict:36
Pict.37
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Pict: 38
Pict:39
a. Following an injury, the patient may be either unconscious or have an altered level
of consciousness.
b. The patient has sustained an injury that has caused a deep laceration or severe
bruises to the scalp or forehead.
c. There is severe pain or swelling at the site of a patient's head injury.
d. There is a deformity of the patient's skull; for example, a depression in the
cranium, a large swelling, or anything that looks unusual about the cranium's
shape.
e. The patient has a bruise or swelling behind the ear (Battle's sign - discoloration
behind the ear caused by a fracture in the base of the skull). This sign may appear
hours to days after the injury.
f. The pupils of the patient's eyes are unequal in size.
g. Tissue around or under both eyes of the patient are discolored ("black eye(s)" or
"raccoon eyes"). This discoloration may appear hours after the injury.
4.2.2.2 REMEMBER:
4.2.2.3 If the patient has no hematoma, infection, or cerebral spinal fluid leak,
a skull fracture presents no danger at this time.
4.2.2.4 CONCUSSION:
A concussion is a mild state of stupor or temporary unconsciousness caused
by a blow to the head. In this condition, there is no laceration or bleeding in
the brain. There is no significant injury to the brain itself.
1. Signs/symptoms of concussion. Signs and symptoms of a concussion
occur immediately. Included are the following:
a. Knowledge that the patient has received a blow to the head, has had
a temporary loss of consciousness, and memory loss are indications
of a concussion.
b. The most important indication of concussion is memory loss for the
exact moment of injury. This is a sign of brain dysfunction. The
patient may never remember the exact moment of injury. His brain
had not had time to record the moment in his memory. Sometimes,
the patient cannot remember events just preceding the moment of
injury, a condition called retrograde. Or, a patient may not be able to
remember events that happened just after the moment of injury, this
condition being called antigrade. Short time memory loss may cause
a patient to ask questions repeatedly about the moments
surrounding his injury.
c. The patient may become combative.
d. Not all patients who have a concussion lose consciousness. But
those who do may regain consciousness anywhere from a few
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NOTE: The time when the patient is lucid and relatively alert is the period between
the recovery from the primary brain injury (usually a concussion) and the onset of
signs/symptoms of brain distortion/displacement by the hematoma. When you know
that a person has had a blow to the head and you see this lucid period between
periods of unconsciousness, suspect the presence of an acute epidural hematoma.
Approximately 40 percent of serious trauma victims have central nervous system injuries. This group
has a death rate twice as high (35 percent versus 17 percent) as that of victims without central nervous
system injuries. Estimations are that head injuries account for 25 percent of all trauma deaths and up to
one-half of all motor vehicle fatalities. The head-injured victim will rarely be cooperative and is often
under the influence of alcohol. When evaluating a patient with a head injury, always assume that the
patient also has a spinal cord injury.
5.1 RESPIRATION:
A head injury produces several types of abnormal respiratory patterns. Possible abnormalities
include:
1. A slowed respiratory rate caused by an acute rise in intracranial pressure.
2. A rapid respiratory rate can be caused if the intracranial pressure continues to rise.
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5.3 PULSE:
A change in pulse rate (either increasing or decreasing) may indicate a serious problem. Note
the following conditions:
1. A slowing pulse will usually accompany the rise in blood pressure observed in a patient
with rising intracranial pressure. A continued rise in intracranial pressure can produce
tachycardia (abnormally fast heart beat), causing death.
2. A rising pulse rate may signal impending shock from bleeding elsewhere in the body.
3. A rapid pulse without another cause is a serious sign.
4. Bradycardia (an abnormally slow heartbeat) with hypertension suggests a rapidly
expanding hematoma.
7. Repeat examinations at intervals and record accurately. Look for trends and changes such
as:
a. Significant rise in blood pressure.
b. Slower pulse occurring late in the cycle.
The most important indication of the severity of a patient's head injury is the patient's level of
consciousness. His initial level of consciousness is also the best indicator of how well the patient will
recover from the head injury. A changed level of consciousness reflects the degree of generalized
injury to the brain. Initially, the patient's level of consciousness can be assessed by testing his
responses to stimuli using the AVPU test.
6.1 A - Is the patient alert? Is the patient looking around to find out where he is?
6.2 V - Does the patient respond to verbal stimuli? When asked a question, does the patient
respond well or at all?
6.3 P - Does the patient respond to painful stimuli? Does the patient respond to a pinch or a pin
prick?
6.4 U - Is the patient unresponsive? Does the patient respond to no stimuli at
Neurological Physical Therapy specializes in the evaluation and treatment of individuals with
movement or functional problems due to congenital and/or acquired disease, trauma or
dysfunction of the nervous system. Medically-Based Fitness works with a broad range of
conditions including:
Balance Deficits
Parkinson's
Multiple Sclerosis
Brain Injury
Spinal Cord Injury
Peripheral Neuropathy
Stroke
Polyneuropathies
Dizziness
Vestibular
Coordination
MBF Physical Therapy restores physical function and improves the efficiency of movement by
addressing the individual client's functional limitations. Our therapists treat the functional
deficits you have in order to improve your daily life. MBF takes an active approach in treatment,
and problem solves long-term solutions with individualized programs treating the whole body.
Our care is transferable to daily life activities making clients happier, healthier, and more
independent.
MBF Physical Therapists excel in treatment of the neurological system. MBF has been working
with individuals with neurological impairments since 1996. There have been three Master's and
two PhD degrees earned through research performed at Medically-Based Fitness. We utilize
outcome based research and the most current research to guide our programming. We have
concrete outcomes that improve the active approach to therapy in order to advance the life of
every client.
functional magnetic resonance imaging (fMRI) before and after treadmill training with body
weight support (BWS). Use of body-weight-supported treadmill training (BWSTT) involves an
overhead harness that can ease the transition into ambulation and eliminates the need for
assistive devices (Figure 1). Because patients are protected from falling, BWSTT allows them
to safely train at greater walking speeds. The intensive, task-specific practice of BWSTT
promotes neural recovery rather than compensation as evidenced by significant improvements
in velocity of locomotion, motor control of the hemiparetic limbs and alterations in fMRI
activation patterns.
Similar to studies of the injured spinal cord and cortex, work in the MPTP-lesioned (1-methyl-
4-phenyl-1,2,3,6-tetrahydropyridine) mouse model of Parkinson's disease has demonstrated
that behavioral recovery and neuroplasticity of the injured basal ganglia may be modulated
through high-intensity treadmill training. We found that central nervous system (CNS)
neuroplasticity, in the form of both neurochemical and morphological adaptations, appears to
underlie the observed behavioral recovery.
In addition to our studies in the MPTP-lesioned mouse, other researchers have found
evidence of enhanced neuroplasticity (behavioral and neurochemical) in the unilateral 6-
OHDA-lesioned rat after forced use18. In this model of basal ganglia injury, rats were forced to
exclusively use their affected limbs by means of ipsilateral limb casting. Casted animals
showed increased affected limb use and increased expression of dopamine in the striatum
compared to noncasted animals. These studies support the notion that intensive behavioral
experience facilitates neuroplasticity in the injured basal ganglia. A neuroprotective effect of
exercise was demonstrated when the ipsilateral forelimb was immobilized prior to the
administration 6-OHDA. By immobilizing the limb that would not be affected by the neurotoxin,
the rats were forced to exercise the forelimb that normally would be impaired when the toxin
was injected. The results showed that the exercised limb, which should have been affected by
the toxin, was not impaired. Additionally, this forced limb use prior to the 6-OHDA injection
appeared to protect the dopaminergic neurons. In fact, 28 days after injection of the toxic
compound, only six percent of dopamine neurons were lost in rats that had undergone forced
use (i.e., exercise) before the injection, compared with a loss of 87 percent in rats that had not
been forced to use one limb prior to the injection of the toxin.
determined by the Unified Parkinson’s Disease Rating Scale (UPDRS), whereas the
conventional therapy group showed negligible differences. Furthermore, both velocity
and cadence over a distance of ten meters improved post-treatment in the BWSTT
group, which persisted even after a four-week period of no training.
Clearly, the potential gains through treadmill training for individuals with PD are
remarkable. However, the specifics of what actually occurs in the structures of the
brain to improve gait and motor performance are not yet known. Currently, researchers
from the Department of Biokinesiology and Physical Therapy at the University of
Southern California are investigating the underlying neural processes by which BWSTT
promotes functional changes in individuals with early-stage Parkinson's disease. As
stated above, evidence now exists that functional improvement and activity-dependent
neuroplasticity can result from the high-intensity, task-specific experience of BWSTT in
animal models and patients with stroke and spinal cord injury. While Miyai et al.,
demonstrated that this intervention also leads to functional performance improvements
in patients with PD, the neural mechanisms supporting the improvements were not
examined. Based on animal models that have linked neuroplasticity with high-intensity
intervention for subjects with PD, we believe that the performance improvements in PD
are also, at least in part, driven by neuroplasticity. We think BWSTT is the most
promising method for inducing neuroplasticity in individuals with Parkinson's disease in
part because of the results we have seen in our mouse model. Additionally, this
method combines some of the most critical characteristics of practice that have been
identified as facilitating activity-dependent plasticity: higher intensity than the individual
is capable of on his or her own gained through the velocity of the treadmill; high
repetition through multiple steps; active engagement on the part of the individual; and
the sensory experience of normal gait kinematics.
To date, no systematic study has examined the effect of high-intensity exercise on
functional outcome in PD and its underlying mechanism (neuroplasticity of the
dopaminergic system). Our interest is to fill the existing gap in the literature and to test
our hypothesis that humans with PD are subject to neuroplasticity and behavioral
recovery through activity-dependent processes when provided with high-intensity
training. By understanding the effects of exercise on neuroplasticity, novel
nonpharmacological therapeutic modalities may be designed to delay or reverse
disease progression in idiopathic Parkinson's disease.
NOTE: If direct pressure is used to control scalp wounds, remember to press only on a stable skull.
i. Be alert for shock. Start an IV of lactated Ringer's solution to keep a vein open and adjust
the rate to the patient's needs.
j. Be observant of possible internal injury. Shock without gross bleeding will not be caused by
brain injury except at the terminal stage. The patient may have internal injuries.
k. Head injury with multiple trauma should be managed the same as any other patient in
shock. Establish an IV with an electrolyte solution and use a pneumatic antishock garment
such as MAST, if necessary and appropriate to control bleeding.
l. A patient with only a head injury should be fluid restricted to decrease cerebral edema.
m. Anticonvulsants may be required.
n. Document carefully. Describe the patient's condition in terms of responsiveness to the
environment.
NOTE: Avoid words such as lethargic, semiconscious, obtunded (to diminish pain or to diminish touch
sensation).
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People who have suffered TBIs may have lost the ability to do certain movements, feel certain
sensations, and speak properly. They will need physical therapy to re-train movements and
sensations so that they can get back as many of these activities as possible. The chance of
getting these lost movements back with physical therapy depends on the age of the individual,
the severity of the injury, and the amount of time that they were unconscious following the
injury.
Many behavioral changes usually accompany TBIs. What these changes are depend on where
the injury occurred in the brain. Some changes may be irritability, a decreased ability to reason,
a decreased concentration, forgetfulness, and personality changes. Some of these changes
may get better with time.
There are many ways to reduce the chances of a traumatic brain injury (TBI), including:
1. Wearing a seat belt every time you drive or ride in a motor vehicle.
2. Buckling your child in the car using a child safety seat, booster seat, or seat belt (according to the
child's height, weight, and age).
Children should start using a booster seat when they outgrow their child safety seats (usually
when they weigh about 40 pounds). They should continue to ride in a booster seat until the
lap/shoulder belts in the car fit properly, typically when they are 4’9” tall.
3. Never driving while under the influence of alcohol or drugs.
4. Wearing a helmet and making sure your children wear helmets when:
Riding a bike, motorcycle, snowmobile, scooter, or all-terrain vehicle;
Playing a contact sport, such as football, ice hockey, or boxing;
Using in-line skates or riding a skateboard;
Batting and running bases in baseball or softball;
Riding a horse; or
Skiing or snowboarding.
5. Making living areas safer for seniors, by:
Removing tripping hazards such as throw rugs and clutter in walkways;
Using nonslip mats in the bathtub and on shower floors;
Installing grab bars next to the toilet and in the tub or shower;
Installing handrails on both sides of stairways;
Improving lighting throughout the home; and
Maintaining a regular physical activity program, if your doctor agrees, to improve lower body
strength and balance.
7. Making sure the surface on your child's playground is made of shock-absorbing material, such as
hardwood mulch or sand.