Chapter 6 Neurologic Pathologies Mosbys PATHOLOGY for Massage Therapists Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 2 Lesson 6.1 Objective Discuss anatomic structures and physiologic processes related to the nervous system. 3 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Overview of Nervous System Functions Helps maintain homeostasis Responsible for: Mental processes Mental processes Behaviors Behaviors Emotional responses Emotional responses 4 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Neuron Structure Dendrites Cell body Nucleus Axon From Applegate E: The anatomy and physiology learning system, ed 3, St. Louis, 2006, Saunders. 5 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Synapse From Salvo S: Massage therapy: principles and practice, ed 3, 2007, St. Louis, Saunders. 6 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Functions of Nervous System Sensory function: receptors detect stimuli and respond by sending information to the CNS Integration function: CNS integrates this information and decides on a response Motor function: motor neurons carry impulses from the CNS to the muscles and glands 7 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Central Nervous System Brain Housed in skull Spinal cord Housed in vertebral column Both brain and spinal cord protected by meninges and cerebrospinal fluid From Applegate E: The anatomy and physiology learning system, ed 3, St. Louis, 2006, Saunders. 8 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Spinal Cord and Spinal Nerves From Rudy EB: Advanced neurological and neurosurgical nursing, St. Louis, 1984, Mosby. 9 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Brain Structure Brainstem Cerebellum Diencephalon Cerebrum From Vidic B, Suarez FR: Photographic atlas of the human body, St. Louis, 1984, Mosby. 10 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Peripheral Nervous System Somatic nervous system Consciously controlled (voluntary) Autonomic nervous system Not consciously controlled (involuntary) Divided into parasympathetic and sympathetic nervous systems 11 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Autonomic Nervous System Parasympathetic Rest-and-digest Sympathetic Fight-or-flight From Thibodeau GA, Patton KT: Anatomy & physiology, ed 6, St. Louis, 2007, Mosby. 12 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Lesson 6.2 Objectives Identify central nervous system disorders and list appropriate massage considerations. List first aid measures to be implemented when a person is experiencing a seizure. Describe appropriate measures used when working with wheelchair-bound clients. 13 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Lesson 6.2 Objectives (contd.) Define infectious diseases of the nervous system and list appropriate massage considerations. 14 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. CNS Disorders Cerebral palsy Spina bifida Seizure disorders Spinal cord injury Attention deficit-hyperactivity disorder Autism 15 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Cerebral Palsy Group of motor disorders; damage to cerebrum from inadequate or reduced blood flow Lighter pressure; avoid joint mobilizations or administer carefully; instruct parents to massage if affected person is a child From Zitelli BJ, Davis HW: Atlas of pediatric physical diagnosis, ed 5, Philadelphia, 2007, Mosby. 16 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Spina Bifida Group of neural tube defects; failure of posterior spinous processes to close (usually lumbar spine) Local contraindication; avoid joint mobilizations and compressions or administer carefully; instruct parents to massage if affected person is a child A and C, Courtesy Michael J. Painter, M.D., Childrens Hospital of Pittsburgh. In Zitelli B, Davis H: Atlas of pediatric physical diagnosis, ed 5, 2007, Mosby; B, from Cohen BA: Atlas of pediatric dermatology, London, 1993, Mosby-Wolf. 17 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Seizure Disorders Explosive episodes of uncontrolled and excessive electrical activity in the brain; two types Partial: limited to single area of brain Generalized: more diffuse involvement Postpone massage if condition is untreated; avoid known triggers; use first aid measures if client experience tonic-clonic seizure 18 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Seizure Disorders (contd.) 19 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. First-Aid for Seizures Remain calm and begin to time seizure Clear area of objects Gently place person on floor (if possible) Place soft material or cushion under head; lift chin slightly to open airway Roll on side if choking or vomiting Remain with person until seizure has ended 20 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. First-Aid for Seizures (contd.) If seizure lasts more than 5 minutes or immediately repeats, call 911, then: Talk calmly to person until help arrives Inform medical personnel how long seizure occurred and symptoms exhibited Write incident report 21 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Spinal Cord Injury Damage to the vertebrae and neural tissues causing loss of movement (paralysis) and loss of sensation distal to area of insult Paraplegia: paralysis of the lower extremities and trunk Quadriplegia: paralysis of the trunk and all extremities Medical clearance is needed 22 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Spinal Cord Injury (contd.) From Lewis SL et al: Medicalsurgical nursing, ed 7, St. Louis, 2007, Mosby. 23 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Spinal Cord Injury (contd.) From Lewis SL et al: Medicalsurgical nursing, ed 7, St. Louis, 2007, Mosby. 24 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Attention Deficit-Hyperactivity Disorder (ADHD) Array of behaviors associated with inattentiveness, hyperactivity, impulsivity, or combination of these Reduce treatment time; instruct parents to massage if affected person is a child 25 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Autism Syndrome of social withdrawal and obsessive behavior; five types ranging from mild and highly functional to severe Reduce treatment time; use firm gliding and compressive strokes with full hand contact; instruct parents to massage if affected person is a child 26 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Wheelchair-Bound Clients Maintain eye level during intake interview Inquire about any medications and their side effects such as drowsiness If indicated, use stimulating strokes at the end of session and ask client to move slowly and carefully Observe wheelchair etiquette 27 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Wheelchair-Bound Clients (contd.) Avoid skin lesions such as bedsores Use light to moderate pressure depending on sensation level Trigger points are often located in shoulders and chest area Limit ROM exercises, especially on neck, spinal column, and hip joints 28 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Infectious Diseases Meningitis Encephalitis Poliomyelitis and Postpolio syndrome 29 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Meningitis Inflammation of the meninges most often the result of a viral or bacterial infection Massage is contraindicated until client completely recovers 30 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Encephalitis Inflammation of the brain usually the result of a viral infection Massage is contraindicated until client completely recovers From Stevens A, Lowe J: Pathology, ed 2, London, 2000, Mosby. 31 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Poliomyelitis Highly contagious viral infection that is now rare Massage contraindicated until client completely recovers 32 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Postpolio Syndrome Collection of symptoms seen in individuals who have previously recovered from polio or who were misdiagnosed, but now considered to have been infected Light massage of shorter duration; omit or only cautiously apply passive stretches and jt. mobs 33 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Lesson 6.3 Objectives Name neurodegenerative diseases and state appropriate massage considerations. List warning signs of Alzheimer disease. Define vascular disorders and list appropriate massage considerations. List warning signs of stroke. Name conditions of the peripheral nervous system and list appropriate massage considerations. 34 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Neurodegenerative Diseases Dementia Alzheimer disease Huntington disease Parkinson disease Multiple sclerosis Amyotrophic lateral sclerosis 35 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Dementia Group of disorders characterized by a decline of mental facilities and personality changes that interfere with work, social activities; two most common types are Alzheimer and vascular Gentle massage of shorter duration during later stages; behavior tolerance is needed 36 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Alzheimer Disease Progressive degenerative disease of the brain Gentle massage of shorter duration during later stages; behavior tolerance is needed From Chabner DE: The language of medicine, ed 8, 2007, Saunders. 37 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Warning Signs of Alzheimer Disease Recent memory loss that impairs functioning at work or home Problems with language Disorientation in time and space; getting confused or lost in familiar places Difficulty completing familiar tasks Distorted judgment Problems with abstract thinking 38 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Warning Signs of Alzheimer Disease (contd.) Misplacing things Repeated and sudden changes in mood and behavior Changes in personality Loss of initiative to do things 39 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Huntington Disease Inherited disorder characterized by motor disturbances, mental deterioration, and abnormal behavior Light massage of shorter duration; omit or only cautiously apply passive stretches and jt. mobs 40 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Parkinson Disease Disorder producing abnormal movements marked by destruction of dopamine- producing neurons in the brain Gentle massage of shorter duration A, from Damjanov I: Pathology for the health professions, ed 3, St. Louis, 2006, Saunders; B from Perkin DG: Mosbys color atlas and text of neurology, London, 1998, Mosby-Wolfe. 41 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Multiple Sclerosis Progressive neural demyelination Massage contraindicated during flare-ups; otherwise gentle massage of shorter duration; evaluate client at each visit as symptoms change From Phipps WJ, Sands J, Marek JF: Medical-surgical nursing: concepts and clinical practice, ed 5, St. Louis, 1999, Mosby. 42 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Amyotrophic Lateral Sclerosis (Lou Gehrigs Disease) Degeneration of motor neurons leading to secondary demyelination; this causes generalized paralysis leaving the affected person immobile Gentle massage of shorter duration 43 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Vascular Disorders Cerebrovascular accident (stroke) Transient ischemic attack Migraine headache 44 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Transient Ischemic Attack Brief episode of impaired brain functioning caused by temporary reduction of blood flow; lasts a few seconds to possibly hours and is characterized by visual disturbances, speech difficulties, and difficulty understanding others No modifications needed 45 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Cerebrovascular Accident (Stroke) Sudden disruption in cerebral blood flow by occluded or ruptured blood vessel Obtain medical clearance during rehab stage; initial sessions should be brief (up to 30 min), gradually increasing to 1 hr From Cotran RS, Kumar V, Collins T: Robbins pathologic basis of disease, ed 6, Philadelphia, 1999, WB Saunders. 46 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Cerebrovascular Accident (contd.) From Cotran RS, Kumar V, Collins T: Robbins pathologic basis of disease, ed 6, Philadelphia, 1999, WB Saunders. 47 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Stroke Warning Signs Sudden or transient weakness, numbness, or tingling in face, arm or leg, or on one side of the body Temporary loss of speech, failure to comprehend, or confusion Sudden loss of vision Sudden severe headache Unusual dizziness or loss of balance 48 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Migraine Headache (Vascular Headache) Severe, recurrent headaches accompanied by symptoms such as visual disturbances and nausea; often provoked by a trigger factor Massage is contraindicated during attack 49 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Peripheral Nerve Disorders Trigeminal neuralgia Bell palsy Myasthenia gravis Guillain-Barr syndrome Peripheral neuropathy Degenerative disc disease Herniated and bulging discs, and radiculopathies Sciatica Carpal tunnel and thoracic outlet syndromes 50 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Trigeminal Neuralgia (Tic douloureux) Condition characterized by excruciating episodic pain in areas supplied by the trigeminal nerve (cranial nerve V) Avoid prone position and avoid massage to the face and scalp From Frazier MS, Drzymkowski J: Essentials of human diseases and conditions, ed 3, St. Louis, 2004, Saunders. 51 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Bells Palsy Condition of facial nerve (cranial nerve VII) causing muscle weakness or paralysis on one side of face Use light gliding strokes directed upward, and kneading, percussion, and vibration on facial muscles From Chabner DE: The language of medicine, ed 8, 2007, Saunders. 52 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Myasthenia Gravis Disorder caused by loss of acetylcholine receptors within the neuromuscular junction resulting in progressive weakness and paralysis Gentle massage of shorter duration From Perkin GD, Hochberg FH, Miller DC: Atlas of clinical neurology, ed 2, London, 1993, Gower Medical Publishing. 53 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Guillain-Barr Syndrome Neurologic inflammatory disease of the peripheral nerves; typically begins as leg weakness and ascends to trunk and arms Massage is contraindicated until the client has fully recovered 54 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Peripheral Neuropathy Inflammation or degeneration of PNS causing symptoms of impaired sensations and movement difficulties Reduced pressure while avoiding hypersensitive areas; if neuropathy in in lower extremities, avoid bolster use 55 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Degenerative Disc Disease Deterioration of the intervertebral discs resulting from the aging process Medical clearance required; once obtained, reduce pressure over affected areas and avoid spinal mobilizations 56 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Herniated Disc, Bulging Disc, and Radiculopathies Herniated disc protrusion of nucleus pulposus through tear in annulus fibrosus Bulging disc similar to herniated disc but nucleus pulposus contained within annular wall Radiculopathy pain radiating along the path of a compressed nerve 57 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Herniated Disc, Bulging Disc, and Radiculopathies (contd.) Symptoms include severe, sharp pain that may worsen with movement; limited ROM; tenderness; paresthesias Postpone massage if pain is severe; otherwise, reduce pressure over affected areas and in areas of paresthesias; avoid spinal mobilizations 58 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Sciatica Inflammation of the sciatic nerve Reduce pressure in areas of paresthesias; avoid use of bolsters on lower extremities From Frazier MS, Drzymkowski J: Essentials of human diseases and conditions, ed 3, St. Louis, 2004, Saunders. 59 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Carpal Tunnel Syndrome Compression of the median nerve within the carpal tunnel Local contraindication if area is inflamed From Courtesy ARO Tool Products/Ingersoll-Rand Professional Tools. In Frazier MS, Drzymkowski JW: Essentials of human diseases and conditions, ed 2, Philadelphia, 2000, WB Saunders; and Beare PG, Myers JL: Adult health nursing, ed 3, St. Louis, 1998, Mosby. 60 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Avoiding Carpal Tunnel Syndrome Strengthen forearm and hand muscles Keep wrists neutral while working Perform regular self-massage of forearms and hands Use variety of strokes during the massage Rest hands by spacing clients Stretch between sessions Lower table height 61 Copyright 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Thoracic Outlet Syndrome Compression or entrapment of neurovascular bundle Avoid vigorous massage if swollen or inflamed; otherwise, massage is helpful From Crossman AR, Neary D: Neuroanatomy: an illustrated color text, Edinburgh, 1995, Churchill Livingstone.