Transcript Chapter 3 Nervous System: Introduction

Chapter 3
Nervous 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)
Chapter 3
Nervous 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
Alzheimer’s Disease
Progressive degeneration of the brain,
leading to memory loss, personality
changes, and death
Progressive destruction of motor neurons
in CNS and PNS
Alzheimer’s Disease
Incidence:
Affects 5% of the U.S. population (4.5
million);
50% of people over 85 years old;
Estimated 16 million people by 2050
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
Alzheimer’s Disease, cont.
Features:
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
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)
Alzheimer’s Disease, cont.
Signs and symptoms (7 phases):
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)
Alzheimer’s Disease, cont.
Diagnosis:
Not definitive until death
Mental tests, ruling out other causes
Differential diagnosis:
Vascular dementia
Stroke/TIA
Parkinson’s
Other
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
Amyotrophic Lateral Sclerosis
Progressive destruction of
motor neurons in CNS and
PNS
Lou Gehrig’s disease
Amyotrophic Lateral Sclerosis
Incidence:
4,000 to 5,000 diagnoses per year,
Mostly 40–70 years old
Three types:
Sporadic (most common)
Familial
Mariana Island type
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)
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
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)
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
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
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
Multiple Sclerosis, cont.
Signs and symptoms:
Weakness
Spasm
Changes in sensation (paresthesia, reduced sensation,
numbness)
Optic neuritis
Urologic dysfunction
Sexual dysfunction
Multiple Sclerosis, cont.
Signs and symptoms:
Difficulty walking
Loss of cognitive function
Depression
Lhermitte’s sign (electrical sensation when neck is in flexion)
Digestive disturbance
Fatigue
Multiple Sclerosis, cont.
Progression:
Relapse/remitting
• (flare/remission)
Primary progressive
• (steady decline in function)
Benign MS
• (1 flare only)
Malignant MS
• (rapidly progressive)
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
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
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”)
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
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
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)
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
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
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…
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…
Peripheral Neuropathy, cont.
Massage?
Depends on cause, client
• Numbness is always a caution!
• May exacerbate or soothe hypersensitivity
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)
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
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
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
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
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
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
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
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
Herpes Zoster, cont.
Treatment:
Antiviral medication, topical anesthetics, antiinflammatories, 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
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
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
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)
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
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)
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
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
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
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
Attention Deficit Hyperactivity
Disorder
Neurobiochemical disorder leading to…
• Inattentiveness
• Hyperactivity
• Poor impulse control
Incidence:
Estimates: 3%–5% of school-age children
Statistics vary widely; underdiagnosed among
some groups, overdiagnosed among others
Boys diagnosed 3:1 over girls
• Girls tend to manifest with withdrawal, not hyperactivity
Up to 4% adults have ADHD
• Coping skills may be better developed
• Often raising children with ADHD as well
Attention Deficit Hyperactivity
Disorder
Incidence:
Estimates: 3%–5% of school-age children
Statistics vary widely; underdiagnosed among
some groups, overdiagnosed among others
Boys diagnosed 3:1 over girls
• Girls tend to manifest with withdrawal,
not hyperactivity
Up to 4% adults have ADHD
• Coping skills may be better developed
• Often raising children with ADHD as well
Attention Deficit Hyperactivity
Disorder, cont.
Etiology:
Largely unknown
Dopamine, noradrenaline pathways are disrupted
Genetic predisposition
Maternal exposures during pregnancy
Signs and symptoms:
Any combination of…
• Inattentiveness
• Hyperactivity
• Impulsivity
Attention Deficit Hyperactivity
Disorder, cont.
Diagnosis:
By observation in different settings
Determining what is ADHD vs. other problems vs.
age-appropriate behavior
Differential diagnosis:
Depression, anxiety disorders, sleep disorders,
learning disability, fetal alcohol syndrome, etc…
Coexisting conditions:
Oppositional defiant disorder, depression, anxiety
disorders
Attention Deficit Hyperactivity
Disorder, cont.
Complications:
People with untreated ADHD have a higher
than normal risk of…
• Poor self esteem, poor school performance,
difficulty maintaining relationships and jobs…
• Substance abuse
• Other addictive behaviors
• Motor vehicle accidents
Attention Deficit Hyperactivity
Disorder, cont.
Treatment:
Psychostimulants
• methylphenidates or dextroamphetamines
• norepinephrine reuptake inhibitor
Learning coping skills along with medications
Massage?
No particular risks
May help to improve behavior in children
May have to adapt technique for client’s tolerance
Anxiety Disorders
Irrational fears, sometimes connected to
behaviors that attempt to control them
Incidence:
Estimates up to 19 million people
Often cannot hold job, lowest
socioeconomic standing
Basic etiology:
“Am I safe?” “Probably not.”
Anxiety Disorders, cont.
Stimuli are interpreted as threatening
Hypervigilance, sympathetic state
Affects limbic system (for memory), basal
ganglia (movement control); frontal lobe
(judgment, decision-making)
Neurotransmitters involved:
• Norepinephrine, GABA, serotonin
Anxiety Disorders, cont.
Signs and symptoms: types of anxiety disorders (5 out of dozens)
General anxiety disorder (GAD)
• Chronic worry, anticipation of disaster
• 4 million people, women >men, 2:1
Panic disorder
• Sudden onset of sympathetic reaction (pounding heart,
dry mouth, hyperventilation, feeling of impending doom);
lasts several minutes to hours
• 2.4 million people, women >men, 2:1
• Complicated by fear of having an episode, leading to
agoraphobia
• Treated most successfully before agoraphobia develops
Anxiety Disorders, cont.
Posttraumatic stress disorder (PTSD)
• 5.2 million in United States, mostly men
• AKA “shell shock”
• Persistent, visceral memories of an ordeal—as a
participant or a witness; leads to hypervigilance
• Can spontaneously resolve, or be a lifelong issue
Anxiety Disorders, cont.
Obsessive–compulsive disorder (OCD)
• Unwelcome thoughts (obsessions) and efforts to control
them (compulsions)
• 3.3 million people; men = women
• Obsessions usually around contamination, sexuality, or
violence
• Compulsions include handwashing, checking locks, etc.,
avoiding touching people, counting, and creating
symmetry
Anxiety Disorders, cont.
Phobias: social and specific:
• Social phobia (social anxiety disorder):
 Fear of being judged, embarrassed
 5.3 million people
 Men more likely to seek treatment
• Specific phobia:
 Intense, irrational fear of something not
inherently dangerous (closed spaces, open
spaces, bridges, elevators, feathers, the
number 13…)
 6.3 million people
Anxiety Disorders, cont.
Treatment:
Depends on disorder
• Medication plus therapy
• Antidepressants, anti-anxieties, beta blockers
Massage?
Various relaxation techniques are recommended;
massage can be appropriate too
Client must perceive it to be safe and nurturing
• This may mean altering the way the work is conducted
Chemical Dependency
Use, abuse, dependence (addiction)
Use: using a substance to change mood or
physical experience
Abuse: use of a substance in a way that is
potentially harmful to user or people close by; use
interferes with normal function; user’s behavior is
unacceptable to others; use continues, in spite of
repeated problems it incurs
Dependence:progressive tolerance; physical
addiction develops (withdrawal symptoms)
Chemical Dependency, cont.
Incidence:
19.5 million over 12 years of age use illicit
drugs/year
14 million abuse alcohol
Chemical Dependency, cont.
Etiology of chemical dependency:
Most stimulants slow dopamine reuptake
Postsynaptic neurons can become desensitized:
takes more drug for same effect
Etiology of alcoholism:
Depresses CNS, but loss of inhibitions can feel
like stimulant
Brain chemistry ultimately changes so that it
cannot function well without alcohol
Chemical Dependency, cont.
Risk factors:
Genetic predisposition
Other mental illness (depression, anxiety
disorders)
Environmental factors (peer pressure,
availability)
Age
Medical history (addiction to sleeping pills,
anti-anxieties, painkillers…)
Chemical Dependency, cont.
Types of addiction:
Psychological: Using feels good!
Physical: Not using feels like I’m going to die!
• Need to avoid withdrawal symptoms
No delineation between legal and illegal
substances: caffeine and nicotine can create the
same patterns as crack
The higher the tolerance, the harder to break the
addiction
Chemical Dependency, cont.
Signs and symptoms (4 main):
Persistent craving
Unable to voluntarily control use
Increasing tolerance
Withdrawal symptoms
Others:
• Increasing time is invested in use and recovery;
responsibilities are neglected; user lives in denial
Chemical Dependency, cont.
Complications (chemical dependency):
Vary, depending on substance
•
•
•
•
Paranoia, coma, convulsions, death
Increased spread of HIV
Accidents (car, boat, industrial)
Child abuse and neglect
Chemical Dependency, cont.
Complications (alcoholism):
• Digestive system: gastritis, liver damage, ulcers,
pancreatitis, increased risk of stomach/esophageal
cancer
• Cardiovascular system: decreased force of heartbeat,
arrhythmia; cardiomyopathy; agglutination of red blood
cells; (ultimately can interfere with clotting, leading to
bleeding)
Chemical Dependency, cont.
Complications (alcoholism):
• Nervous system: memory loss, slowed reflexes, organic
brain syndrome
• Immune system: suppressed activity, vulnerability to
infection
• Reproductive system: reduced sex drive, fetal alcohol
syndrome
• Others: ½ car fatalities; 40% industrial accidents; 65%
adult drownings; 100,000 deaths/year
Chemical Dependency, cont.
Treatment:
Recognize that a problem exists
Detoxification (may be treated with other meds)
Rehabilitation
• New coping skills
After-care is the most important feature
Chemical Dependency, cont.
Massage?
Can be used to help with withdrawal symptoms
Be careful about other conditions that may exist
• Hepatitis B, C; HIV/AIDS, cirrhosis, etc.
Clients who are drunk or high during a session are
not good candidates for massage
Depression
Genetic predisposition + CNS chemical
imbalances + triggering event leads to
persistent sense of loss and hopelessness
Incidence:
Estimates of 10%–20% of the U.S.
population (not all seek help):
11–19 million people/year
Depression, cont.
Factors (all overlap each other):
Neurotransmitter imbalance
• Serotonin, norepinephrine, dopamine; too low? Or too
high, leading to resistance?
Hormonal imbalance
• Estrogen, progesterone, endorphins, cortisol
Hypothalamus-pituitary-adrenal axis (HPA axis)
• Stress response system between hypothalamus,
pituitary, adrenal gland; high CRF levels means more
stress responses
Atrophy in hippocampus
• May be related to hypersecretion of cortisol
Depression, cont.
Causes:
Genetics
Environmental triggers
Personality traits
Chronic illness
Other
• Hypothyroidism, chemical dependency,
nutritional deficiencies, etc
Depression, cont.
Signs and symptoms (6 main ones):
Persistent sad or empty feeling
Less enjoyment from activities
Deep sense of guilt or disappointment with self
Hopelessness: things will never get better
Irritability
Change in sleeping habits
Others:
• Poor concentration; weight changes; loss of energy;
persistent physical pain (headaches, indigestion);
suicidal thoughts or behaviors
Depression, cont.
Types of depression (5 of many)
Major depressive disorder
• Severe symptoms, 2+ weeks; untreated episodes can
last 6–18 months, with 4–6 in a lifetime (10 years of
feeling awful!)
Dysthymia
• Less severe symptoms, much longer lasting (months or
years)
Bipolar disease
• Aka, manic depression; cycles from mania to depression
Seasonal affective disorder
• Related to lack of sunlight, melatonin
Postpartum depression
• Combination of hormonal swings, unmet expectations,
Depression, cont.
Treatment:
Antidepressants:
• SSRIs, MAOIs, tricyclics
 Can take weeks to take effect, side effects at the
beginning
• Lithium for bipolar
 “smooth out” mood swings
Psychotherapy
Other therapies
• Light therapy for SAD
• Electroconvulsive therapy
• St. John’s Wort
Depression, cont.
Complications:
15% of major depressives successfully commit suicide
Correlation to other disorders:
• Heart attack and other cardiovascular disease
Massage?
Improved efficiency of HPA axis
Sympathetic to parasympathetic state
• Reduction in cortisol, improvement in serotonin
Changes brain activity to more balanced emotional state
Risks:
• Respect medications, doctor’s role in prescribing them
• Respect appropriate boundaries with emotionally fragile clients
Eating Disorders
Poor eating habits that ultimately can become
life-threatening
Anorexia nervosa
Bulimia nervosa
Compulsive overeating
Incidence:
Usually girls between adolescence and college
(for anorexia and bulimia);
Girls > boys by 10:1
Eating Disorders, cont.
Etiology of anorexia and bulimia:
Over-achievers, exerting power and control
Serotonin disturbance (?)
Can reach the point where it is difficult or
impossible to return to healthy eating
Etiology of overeating:
Touch deprivation
Protection (touch abuse survivors)
Eating Disorders, cont.
Signs and symptoms:
Anorexia:
•
•
•
•
Avoid eating in public
Distorted self image
Restrictive: self-starvation
Purge-type: barely sufficient nutrition +
behaviors to eliminate it (vomiting, laxatives,
excessive exercise)
• Lanugo
Eating Disorders, cont.
Signs and symptoms:
Bulimia
• Appear to eat normally; binge in private
• Binges triggered by stress
• Followed by purging or exercise
Compulsive overeating
•
•
•
•
Public and private eating
Not compensated with purging, exercise
May have rapid weight gain
Long-term problems generally more manageable than
with anorexia, bulimia
Eating Disorders, cont.
Complications:
Anorexia:
• Arrhythmia, bradycardia, hypotension; infertility,
osteoporosis; purging can cause colon dysfunction,
esophageal damage
Bulimia:
• Erosion of tooth enamel; esophageal ulcers, strictures,
rupture; colon dysfunction; electrolyte imbalances
Compulsive overeating:
• Cardiovascular disease, arthritis
Eating Disorders, cont.
Treatment:
Must focus on control issues, not eating
Address neurotransmitter imbalances
Address overlap with other psychiatric disorders
• OCD, depression, etc.
Massage?
Can be a wonderful positive body experience
Watch for cardiovascular problems (arrhythmia,
etc.)
Bell’s Palsy
Damage to cranial nerve VII (facial nerve):
motor control for the face (Fig. 3.7)
Incidence: 40,000 diagnoses/year in the United
States
Type of peripheral neuritis:
Reactivation of herpes simplex puts pressure on
facial nerve
Lyme disease
Depressed immunity, lack of sleep, stress may trigger
episode
75% cases preceded by a cold
Could be tumor, bone spur, other mechanical irritation
Bell’s Palsy, cont.
Signs and symptoms:
Unilateral flaccid paralysis of the face (Fig. 3.8)
• Can lead to corneal damage
Sudden onset (wake up with it)
Not sharply painful
• Hyperacusis
• Taste distortion
Treatment:
Often self-limited
Anti-inflammatories, acyclovir (anti-viral)
Surgery if necessary
Bell’s Palsy, cont.
Prognosis:
Most people have full or nearly full recovery within
weeks or months
Some do not recover full function
Massage?
Motor paralysis with sensation intact: massage is
safe, appropriate, and important to maintain the
health of facial muscles during recovery
Get information on underlying cautions (tumor,
Lyme disease, etc.)
Work with health care team
Cerebral Palsy
Any of a group of injuries to the brain that
occur prenatally, during birth, or in early
infancy
Incidence:
2–4:1,000 live births
1,500 new cases/year
500,000-1 million in United States today
Cerebral Palsy, cont.
Damage to basal ganglia and cerebrum
Multifactorial problems:
Prenatal causes: maternal illness (infection,
hyperthyroidism, diabetes, Rh sensitivity)
Birth trauma: anoxia/asphyxia, head trauma
Acquired CP: head trauma in infancy, infection,
hemorrhage, neoplasms
Cerebral Palsy, cont.
Signs and symptoms (types of CP):
Spastic CP
• Most common (50%–80%); spasticity and “knife-clasp”
effect (flexors win the battle for tightness, extensors give
up entirely)
Athetoid CP
• 30%; weak muscles, writhing movements
Ataxic CP
• <10%; chronic shaking and tremors, poor balance
Mixed CP
• Any combination of the above
Also classified as hemiplegic, diplegic,
quadriplegic CP
Cerebral Palsy, cont.
Types may come and go or change from one to
another as child grows
Severity ranges from subtle to severe
Not progressive
Complications:
Partial or total hearing loss
Strabismus
Some mental retardation
Seizure disorders
Contractures
Scoliosis
Cerebral Palsy, cont.
Treatment:
Work on life skills, orthopedic aids
Medicate for seizures if necessary
Physical therapy
• Massage can be useful here too
Massage?
Can be very useful for helping with muscle tone,
balance between flexors and extensors
Be cautious when client cannot communicate well;
areas of numbness
Reflex Sympathetic Dystrophy
Syndrome
Self-perpetuating signs and symptoms
usually related to injury or trauma
• Also called causalgia (umbrella term for
burning pain syndromes), sympathetic
maintained pain syndrome, complex regional
path syndrome type 1 and 2, Sudeck's
atrophy
Reflex Sympathetic Dystrophy
Syndrome
Incidence:
Statistics vary widely
2%–5% of all peripheral nerve injuries?
21% of all hemiplegic injuries?
Most diagnoses 40–60 years old
Estimated 5–7 million in the United States
Men vs. women? Statistics vary
Reflex Sympathetic Dystrophy
Syndrome, cont.
Usual pattern:
Injury or trauma to hand (can be other body part);
often a high-velocity wound (gunshot, shrapnel)
Pain creates a sympathetic response; this
reinforces pain sensation, which reinforces
sympathetic response, ad infinitum
Physiologic changes in tissue: vascular
adaptation, atrophy
Changes can spread proximally, even to
contralateral limb
Reflex Sympathetic Dystrophy
Syndrome, cont.
Signs and symptoms:
Constant, burning pain w/ little or no
stimulus
Local inflammation, sweating
Spasm of local skeletal and smooth muscle
tissue (blood vessels)
Chronic insomnia (can lead to secondary
problems)
Reflex Sympathetic Dystrophy
Syndrome, cont.
Stages:
I: 1–3 months after injury; severe burning pain and
muscle spasm; excessive hair and nail growth if
on hand or foot; red, hot, sweaty skin (acute
stage) (Fig. 3.9)
II: 3–6 months; swelling spreads proximally; nails
become brittle; skin becomes bluish; intense pain,
atrophy of muscle, bone, joints (dystrophic stage)
III: Irreversible damage; affected area spreads up
limb, to other side; pain is self-sustaining, brain
chemistry changes to reinforce sensation
Reflex Sympathetic Dystrophy
Syndrome, cont.
Diagnosis:
Thermography, x-ray to look for bone thinning
Treatment:
Depends on the stage; the earlier applied, the
more successful
• Analgesics, moist heat (ice is contraindicated) in early
stage
• Morphine pumps, TENS machines, calcium channel
blockers, sympathectomy in later stages
Reflex Sympathetic Dystrophy
Syndrome, cont.
Massage?
RSDS locally contraindicates massage
because of hypersensitivity
May be useful with physical therapy to
preserve function
May improve quality of life, quality of sleep,
if not the central problem
Spina Bifida
Neural tube defect: spine fails to close
over the spinal cord
“Cleft spine”
Incidence:
1:1,000 live births
Some genetic component
Most cases have no family history
Spina Bifida, cont.
Contributing factors:
Folic acid deficiency
Diabetes
Some anti-seizure medication
Genetics (most have no history)
Spina Bifida, cont.
Types of spina bifida:
Spina bifida occulta (Fig. 3.10)
• “Hidden”; one lumbar vertebral arch does not fuse
• May never be found, or found by incidental x-ray
• Dimple or tuft of hair at site may be present
Spina bifida meningocele (Fig. 3.11)
• Rarest version
• Dura and arachnoid press through at cleft, forming cyst
Spina bifida myelomeningocele (Fig. 3.12)
• 94% of diagnoses
• Meninges and spinal cord press through cleft
• High risk of infection
Spina Bifida, cont.
Complications:
Hydrocephalus
Retardation; learning problems
Latex allergy (multiple surgeries)
Decubitus ulcers
Postural deviations
Contractures
Spina Bifida, cont.
Treatment:
Reduce any cyst as quickly as possible
Other corrective surgeries
Aggressive physical therapy early in infancy
Assistive devices (canes, crutches, wheelchair,
etc.)
Massage?
Based on level of function, presence of sensation,
other complications
Can be a useful adjunct to physical therapy
Work with health care team
Spinal cord injury
Damage to tissue in spinal cord (Fig. 3.13)
Five categories:
Concussion
• Tissue is irritated but not structurally damaged
Contusion
• Bleeding in spinal cord
Compression
• Mechanical pressure from a disc, tumor, bone spur, etc.
Laceration
• Cord is partially cut
Transection
• Cord is completely severed
Spinal Cord Injury, cont.
Incidence:
10–11,000/year
183–283,000 SCI survivors in the United States
Men > women, 4:1
Motor vehicle accidents most common cause;
followed by gunshot wounds, falls, sport injuries,
and other accidents
Most common levels of injury, in order:
• C5, C4, C6, T12, L1
51.6% are quadriplegic (tetraplegic); 46.3% are
paraplegic
Spinal Cord Injury, cont.
Damage related to trauma plus…
Bleeding
Edema
Free radical activity
Accumulation of scar tissue
White blood cell attack
Other factors
Much of this can be limited, leading to a better
prognosis!
Spinal Cord Injury, cont.
Right after injury is “spinal cord shock”
May last up to 3 months
Secondary responses begin here
• Flaccidity, low blood pressure, etc.
Hypertonicity begins when inflammation subsides
Hypertonicity reflects CNS (upper motor neuron)
damage
Hypotonicity reflects nerve roots or PNS (lower
motor neuron) damage
Injury to the cauda equina and higher may have
both
Spinal Cord Injury, cont.
Signs and symptoms:
The higher the injury, the more the damage
Anterior cord damage: motor function
Posterior cord damage: sensory function
• Touch, proprioception, vibration
Lateral cord damage: sensory function
• Pain and temperature sensation
Spinal Cord Injury, cont.
Complications (these are important!):
Decubitus ulcers
Heterotopic ossification
DVT, pulmonary embolism
Respiratory infection
Urinary tract infection
Autonomic hyperreflexia
Cardiovascular disease
Numbness
Pain
Spasticity, contractures
Spinal Cord Injury, cont.
Treatment:
Remove source of pressure, damage
Anti-inflammatories to limit secondary
damage
Other treatments depend on injuries
• Electrode implants, surgical transfer of tendons,
physical/occupational therapy
Research in growth of CNS neurons—
always changing
Spinal Cord Injury, cont.
Massage?
Respect possible complications; work as
part of health care team
Work with remaining muscle function to
prevent atrophy, proprioceptive
misinformation
Spinal Cord Injury, cont.
Nerve damage vocabulary:
Paresthesia: pins and needles, tingling
Hyperkinesia: excessive motor activity
Hypertonia: high tone, tension
Hypotonia: low tone
Spasticity: type of hypertonia
Paralysis: loss of nervous system function
Pareses: partial paralysis
Flaccid paralysis: sign of PNS damage,
hypotonicity
Spastic paralysis: sign of CNS damage,
hypertonicity
Spinal Cord Injury, cont.
Nerve damage vocabulary, cont.:
Hemiplegia (left or right side)
Paraplegia (lower part of body)
Diplegia (upper or lower extremities)
Tetraplegia/quadriplegia (from neck down)
Stroke
Damage to brain cells from oxygen
deprivation (see animation)
Cerebrovascular accident (CVA)
Incidence:
•
•
•
•
#3 cause of death in the United States
#1 cause of adult disability
700,000 /year (1:45 seconds)
170,000 deaths/year (1:3 minutes)
Stroke, cont.
Ischemic strokes (Fig. 3.14) :
Cerebral thrombosis:
• clot (probably from carotid artery, atherosclerosis) is
lodged in cerebral artery; brain cells starve
• 88% of all CVAs
• Related to “transient ischemic attack” (TIA): mini-strokes
Embolism:
• Embolus (probably from inefficient heartbeat, fibrillations)
lodged in cerebral artery; brain cells starve
• 8%–14% of all CVAs
Stroke, cont.
Hemorrhagic strokes (Fig. 3.15):
Cerebral hemorrhage
• Blood vessel in cerebrum ruptures, brain cells
die
• Related to aneurysm, chronic hypertension,
head trauma, congenital weakness or
malformation of blood vessels
Subarachnoid hemorrhage
• Blood vessel on brain surface ruptures,
leakage puts pressure on brain
Stroke, cont.
Risk Factors:
Controllable:
• Cardiovascular health; diabetes, smoking, etc.
Uncontrollable:
• Age, gender, race, genetics, previous stroke
Stroke, cont.
Signs and symptoms:
Sudden onset of unilateral weakness, numbness,
paralysis
Suddenly blurred or decreased vision; asymmetric
dilation of pupils
Difficulty with language (speaking or
comprehension)
Dizziness, clumsiness, vertigo
“Thunderclap” headache
Loss of consciousness
Stroke, cont.
Treatment:
Determine whether CVA was ischemic or
hemorrhagic
• Anticoagulants for ischemic
• Anti-inflammatories to limit secondary damage
• Physical and other therapies during recovery
Massage?
Get information of cardiovascular health
Be cautious about numbness
Otherwise, massage can be useful in
rehabilitation, working for proprioceptive accuracy
and fullest possible recovery
Traumatic Brain Injury
Injury to brain not related to disease
Vehicular accidents, gunshots, falls, sports
accidents, physical violence are leading causes
Incidence:
1.5 million TBIs/year (approximately every 21
seconds)
70,000 deaths/year
2.5–6.5 million TBI survivors in the United States
Traumatic Brain Injury, cont.
Classifications of head injuries:
Skull fracture
• Open injury less dangerous than closed injury (less
pressure)
Penetrating injury
• Gunshot wound or knife; leading cause of death by TBI
Concussion
• Most common type; jarring; loss of consciousness <20
minutes
Contusion
• Bruising inside brain; “coup-contrecoup” when brain hits
both sides of the cranium
Traumatic Brain Injury, cont.
Classifications of head injuries, cont.
Diffuse axonal injury
• Internal tearing, as with shaken baby syndrome, whiplash
Anoxic/hypoxic brain injury
• Insufficient supply of O2; apnea, obstructed airway, stroke,
carbon monoxide poisoning
Hemorrhage
• Bleeding inside or on surface of brain
Hematoma
• Accumulation of coagulated blood, usually on surface of brain
Edema
• Secondary inflammation following any kind of brain trauma
Traumatic Brain Injury, cont.
Signs and symptoms:
Depend on location and severity of injury
• Frontal lobe (most common): language and
motor dysfunction
• Injuries closer to brainstem lead to massive
loss of function
Other symptoms:
• Seizures, cognitive dysfunction, movement
disorders, emotional volatility…
Traumatic Brain Injury, cont.
Treatment:
Surgery
Therapy to recover as much
function as possible
Prevention
Helmets, seatbelts, driving sober
and alert, safety features in
homes, storage of firearms
Traumatic Brain Injury, cont.
Massage?
Can be helpful for rehabilitation,
maintenance
Can work for best efficiency of muscles,
connective tissues
Get information about type of injury,
possible complications
Work with health care team
Trigeminal Neuralgia
Irritation and pain of the trigeminal
nerve Cranial Nerve V,
(Fig. 3.16)
• Also called tic douloureux: “unhappy
tic”
Incidence:
• 16:100,000;
• women > men
• 50 years +
Trigeminal Neuralgia, cont.
Primary
Idiopathic, unrelated to underlying disorder
Secondary
Mechanical pressure on trigeminal nerve
from some structural anomaly:
• Tumor, bone spur, infection, inflammation
• Most common is small artery that strangulates
the nerve
Trigeminal Neuralgia, cont.
Triggered by…
Chewing, swallowing, a cold draft, touch,
nothing at all…
Signs and symptoms:
“Hot poker” pain on affected side of the
face
• Tic is muscle spasm in response to pain
10–60 seconds, can be in rapid succession
Trigeminal Neuralgia, cont.
Treatment:
Depends on source of pain
•
•
•
•
Clear up infection, other musculoskeletal issues
Acupuncture for improved nerve transmission
Painkillers, anti-seizure medication
Surgery/injections to decompress or disable the nerve
Massage?
Avoid touching or putting pressure on the face
Massage elsewhere is safe and appropriate
Guillain-Barré Syndrome
Inflammation, destruction of myelin in PNS
Also called acute idiopathic polyneuritis
Incidence:
1:100,000
Men slightly more than women
Guillain-Barré Syndrome,
cont.
Best guess is that preceding infection of
respiratory or GI tract stimulates immune
response that is misdirected against peripheral
nerve myelin sheaths
Also seen with pregnancy, surgery, some vaccines
(swine flu, 1976)
Guillain-Barré Syndrome,
cont.
Myelin sheaths are attacked and destroyed
Starts distally, progresses proximally
May affect cranial nerves too
Usually spontaneously resolves
Guillain-Barré Syndrome,
cont.
Signs and symptoms:
Unpredictable
• Fast onset, symmetric loss of function
• Usually starts in legs, moves toward trunk
May affect breathing center; ventilator may be
necessary
Weakness, paresthesia
Dull reflexes
Symptoms peak 2–3 weeks after onset, then
subside
Guillain-Barré Syndrome,
cont.
Treatment:
Plasmapheresis
Injections of gamma globulins
These can shorten episode by 50%
Other treatments:
• Anticoagulants, ventilator,
occupational/physical therapy during recovery
Guillain-Barré Syndrome,
cont.
Prognosis:
Generally good: full or nearly full recovery
• May take 18 months+
Some don’t have full recovery; 3%–4% die
Some have relapse later in life
Guillain-Barré Syndrome,
cont.
Massage?
Avoid during acute stage
May be helpful during recovery along with physical
and occupational therapy
Be cautious about sensation: numbness is
potentially dangerous
Headaches
One of the most common physical
problems in humans
Types of headaches (with some
significant overlap):
•
•
•
•
Tension-type
Vascular
Chemical
Traction-inflammatory
Headaches
General etiology:
Varies, but usually involves drops in
serotonin; neuropeptides from
trigeminal nerve dilate blood
vessels
Headaches, cont.
Tension headaches
Most common variety (90%–92%)
Triggered by biomechanical stresses
• Muscle imbalance, trigger points, referred pain
(Fig. 3.17)
• Ligamentous irritation, referred pain
• Subluxation/fixation of cervical vertebrae
• Eyestrain
• Stress
Headaches, cont.
Vascular headaches
Related to too much fluid
(blood, mucus) in the head
• Pain throbs with heartbeat
Headaches, cont.
Migraines:
• Women more than men
• vasoconstriction followed by
vasodilation
• Pain on ½ of head (“hemicraine”)
• May have aura, other symptoms
Headaches, cont.
Vascular headaches, cont.
Cluster headaches:
• Men more than women
• Occur in succession, last days or weeks at a
time
• Unilateral pain, watering eye and nose
• Unpredictable triggers
Headaches, cont.
Vascular headaches, cont.
Sinus headaches:
• Fluid accumulation in sinuses; pressure in
cranium
• Throbs with heartbeat
• Can be allergic or infectious
Headaches, cont.
Chemical headaches:
Low blood sugar (getting too hungry)
Hormonal shifts with menstrual cycle (overlap with
migraines)
Extreme dehydration (physical exertion and/or
alcohol use: hangover)
“Rebound” headache from painkiller overuse
Headaches, cont.
Traction/inflammatory headaches:
With fever: indicates infection
With dizziness, slurred speech, motor problems:
indicates stroke, tumor, aneurysm…
Medical emergency
Headaches, cont.
Treatment:
Depends on cause
• Try to understand chronic headache—not just
cover it up
• For others, try to prevent, or try to shorten the
episode
 NSAIDs for tension headaches
 SSRIs, beta blockers, calcium channel
blockers (alter vasodilation) for vascular
headaches
Headaches, cont.
Massage?
Depends on cause
• Tension headaches respond extremely well,
especially when therapist can unravel
contributing factors in posture, movement
patterns
• Most vascular headache patients would rather
wait until later
• Headaches due to infection or trauma need
medical attention first
Seizure Disorders
Any CNS disturbance leading to seizures
Epilepsy is a subset
Incidence:
1% of the U.S. population will have a
seizure at some point
25% of those may be diagnosed with
epilepsy
• 30,000 diagnoses/year; approximately 4
million in the United States
(75% of seizures are not diagnosed as
epilepsy)
Seizure Disorders, cont.
“Lightning storm” of electrical discharge at
synapses in brain
Triggers vary:
Changing light level, strobing
Sounds or notes of music
Stress, illness
Deficient inhibitory neurotransmitters/ excessive
excitatory neurotransmitters?
Sometimes linked to specific brain injury of
structural problem; usually not
Seizure Disorders, cont.
Signs and symptoms (types of seizures):
Partial seizures: affect isolated areas of
the brain
• Simple partial: no change in consciousness;
weak, numb, smell/taste hallucinations, vertigo,
tics
• Complex partial: temporal lobe; repetitive
behaviors, laughing, fear, hallucinations
Seizure Disorders, cont.
Signs and symptoms (types of seizures), cont.
Generalized seizures: whole brain is involved
• Absence seizures: short episodes of loss of
consciousness (“checking out”), 5–10 seconds
• Myoclonic seizures: bilateral muscular jerking; subtle to
severe, usually in young patients
• Tonic–clonic seizures: used to be called “grand mal”;
uncontrolled whole body movements, 5–20 minutes; loss
of consciousness
• Status epilepticus: prolonged or successive tonic–clonic
seizure; medical emergency
Seizure Disorders, cont.
Treatment:
• Antiseizure medications
 Some are poorly tolerated
• Ketogenic diet
• Surgery, vagus nerve stimulation
Massage?
During a seizure, stop work and call for help if
necessary
Clients with history of seizures can safely receive
massage
Postseizure injuries are common
Sleep Disorders
A group of disorders in which it is difficult
to get to sleep, stay asleep, or wake up
refreshed
Incidence:
40 million in the United States
report sleep problems
Increases with age
Sleep Disorders, cont.
Stages of sleep:
Stage I: light sleep, easily wakened; hypnic
myoclonia
Stage II: eyes stop moving; occasional bursts of
brain activity
Stage III: delta waves begin
Stage IV: Only delta waves; deepest sleep
Rapid eye movement (REM): rapid, shallow
breathing, blood pressure is like waking; dreaming
occurs
Cycle through each stage and start over
Each night: 20% REM, 50% II, 30% other stages
Sleep Disorders, cont.
Types of sleep disorders (5 of 70):
Insomnia: “lack of sleep”; transient or chronic
• Transient usually related to habits (caffeine, exercise,
sleeping room, stress)
• Chronic usually related to underlying disorder
(hyperthyroidism, depression, fibromyalgia, etc.)
Sleep Disorders, cont.
Sleep Apnea: absence of breath; 18
million in the United States?
• Obstructive sleep apnea: mechanical
problem; airway collapses, O2 levels fall,
muscles tighten, loud gasp or snore
• Central sleep apnea: decreased respiratory
drive (CNS problem)
Sleep Disorders, cont.
Types of sleep disorders, cont.
Restless leg syndrome (RLS): constant
crawling, tickling sensation in legs, relieved
by rubbing, movement; most pronounced
at night
• Related to periodic limb movement disorder
• Mostly affects elderly
Sleep Disorders, cont.
Types of sleep disorders, cont.
Narcolepsy: “sleep seizure”; sleep attacks
at moments of stress or extreme emotion
• 250,000 in the United States
• Sudden loss of all muscle tone; seconds to 30
minutes
• Poor nighttime sleep
Sleep Disorders, cont.
Types of sleep disorders, cont.
Circadian rhythm disruption: people forced to
be active out of sync with sunlight (changing time
zone, shift changes, graveyard shift)
• Higher than average risk for many health problems
Signs and symptoms:
Excessive daytime sleepiness; irritability, poor
concentration, poor short-term memory, other
health problems
Sleep Disorders, cont.
Complications:
1.5% of all motor vehicle accidents
Industrial accidents
Hallucinations and psychosis (lack of REM)
Fibromyalgia (lack of Stage IV)
Sleep Disorders, cont.
Treatment:
Adjust behaviors
• Caffeine, sugar, alcohol, when to exercise, environment
of sleeping room
Sleeping aids generally discouraged; can become
addictive
Surgery if necessary for sleep apnea
Sleep Disorders, cont.
Massage?
May increase time spent in Stage III
and IV sleep
May be opportunity to recognize
sleep apnea
Great idea!