PHYSICAL THERAPY PRINCIPALS & METHODS                                                                           PTP&M:004 ...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                                     ...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                                     ...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                           PTP&M:004 ...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                           PTP&M:004 ...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                           PTP&M:004 ...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                           PTP&M:004 ...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                           PTP&M:004 ...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                           PTP&M:004 ...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PHYSICAL THERAPY PRINCIPALS & METHODS                                                                         PTP&M:004 Re...
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
PTP&M007 PTM of Neurological_Neurosurgical conditions Medi…
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  1. 1. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 1 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASESPEC. BY: Abdulrehman S. MullaDATE: 03/21/2009REVISION HISTORYREV. DESCRIPTION CN No. BY DATE01 Initial Release PT0001 ASM 03/24/2009 Medicine: It’s a noble profession, it serves humanity.1
  2. 2. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 2 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.TABLE OF CONTENTS PAGE1.0 NERVOUS SYSTEM DISEASES: .................................................................................................................................................................... 4 1.1 THE CENTRAL NERVOUS SYSTEM:............................................................................................................................................. 4 Pict:1.......................................................................................................................................................................................................4 1.1.1 BRAIN: ............................................................................................................................................................................. 5 Pict:2.......................................................................................................................................................................................................5 1.1.2 THE SPINAL CORD:........................................................................................................................................................ 82.0 SPINAL CORD TRAUMA: .............................................................................................................................................................................. 12 2.1 DEFINITION: .................................................................................................................................................................................. 12 2.2 CAUSES:........................................................................................................................................................................................ 12 2.2 SYMPTOMS:.................................................................................................................................................................................. 14 2.3 CERVICAL (NEAR THE NECK) INJURIES: .................................................................................................................................. 15 2.4 THORACIC (CHEST-LEVEL) INJURIES: ...................................................................................................................................... 15 2.5 LUMBAR SACRAL SHOWN IN PICT:17 (LOWER-BACK) INJURIES .......................................................................................... 17 2.6 PHYSICAL THERAPY FOR SPINAL CORD INJURY:................................................................................................................... 20 2.6.1 RESPIRATORY CARE: ................................................................................................................................................. 20 A. MANAGEMENT:..............................................................................................................................................................................20 B. DISCHARGE AND FOLLOW-UP: ...................................................................................................................................................21 2.7 RANGE OF MOTION: .................................................................................................................................................................... 21 2.7.1 INCREASED STRENGTH: ............................................................................................................................................ 22 2.8 MUSCLE STRENGTHENING: ....................................................................................................................................................... 22 2.9 COORDINATION AND BALANCE EXERCISES: .......................................................................................................................... 23 2.9.1 AMBULATION EXERCISES: ......................................................................................................................................... 24 2.9.2 GENERAL CONDITIONING EXERCISES:.................................................................................................................... 25 2.10 WHEELCHAIR SKILLS: ................................................................................................................................................................. 26 2.11 TRANSFERS:................................................................................................................................................................................. 263.0 HEAD INJURY:............................................................................................................................................................................................... 27 3.1 PATHOPHYSIOLOGY: .................................................................................................................................................. 28 3.1.1 HEAD INJURY: .............................................................................................................................................................. 28 3.1.2 BRAIN INJURIES:.......................................................................................................................................................... 28 3.2 INTRACRANIAL PRESSURE (ICP):.............................................................................................................................................. 30 3.2.2 PROGRESSIVE LEVELS OF INTRACRANIAL PRESSURE: ....................................................................................... 31 3.2.3 ANOXIC BRAIN INJURY: .............................................................................................................................................. 344.0. SPECIFIC TYPES OF HEAD INJURY: .......................................................................................................................................................... 35 4.1 SCALP WOUNDS: ......................................................................................................................................................................... 35 4.2 SKULL INJURIES:.......................................................................................................................................................................... 36 4.2.1 SIGNS/SYMPTOMS OF SKULL INJURIES:.................................................................................................................. 36 4.2.2 TREATMENT FOR SKULL FRACTURE:....................................................................................................................... 37 A. FOLLOW THESE GENERAL PROCEDURES:...............................................................................................................................37 B. REMEMBER: ..................................................................................................................................................................37 C. CONCUSSION:...............................................................................................................................................................37 D. CEREBRAL CONTUSION: .............................................................................................................................................................38 E. INTRACRANIAL HEMATOMA: ......................................................................................................................................................385-0 GENERAL ASSESSMENT OF HEAD TRAUMA:........................................................................................................................................... 40 5.1 RESPIRATION: ............................................................................................................................................................................. 40 5.2 BLOOD PRESSURE: ..................................................................................................................................................................... 40 5.3 PULSE:.......................................................................................................................................................................................... 40 5.4 GENERAL EXAMINATION: ........................................................................................................................................................... 41 5.5 SPECIAL CONSIDERATIONS. BE AWARE THAT: ...................................................................................................................... 41 5.6 NEUROLOGICAL EXAMINATION: ................................................................................................................................................ 416.0 JUDGING LEVEL OF SEVERITY OF HEAD INJURY: .................................................................................................................................. 427.0 LEVELS OF HEAD INJURY: ......................................................................................................................................................................... 43 7.1 THE GLASGOW COMA SCALE: ................................................................................................................................................... 43 7.3 POINTS ASSIGNED RESPONSES ON THE GLASGOW COMA SCALE: .................................................................................. 43 7.3.1 EYE OPENING: ............................................................................................................................................................. 43 7.3.2 VERBAL RESPONSE: ................................................................................................................................................... 43 7.3.3 MOTOR RESPONSE:.................................................................................................................................................... 44 7.3.4 MEANING OF TOTAL POINTS ON GLASGOW COMA SCALE:.................................................................................. 44 Medicine: It’s a noble profession, it serves humanity.2
  3. 3. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 3 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.8.0 GENERAL MANAGEMENT OF HEAD TRAUMA: ......................................................................................................................................... 45 8.1 PHYSICAL THERAPY:................................................................................................................................................................... 45 8.2 PARKINSONS SPECIFIC PROGRAMMING: ............................................................................................................................... 46 8.3 PHYSICAL THERAPY FOR PARKINSONS ADDRESSES: ......................................................................................................... 46 8.4 PHYSICAL THERAPY FOR INDIVIDUALS WITH PARKINSON’S DISEASE: .............................................................................. 46 8.4.2 CURRENT APPROACHES TO EXERCISE IN PD:....................................................................................................... 48 8.5 VESTIBULAR THERAPY: .............................................................................................................................................................. 509.0 PREVENTION STRATEGIES: ....................................................................................................................................................................... 52 Medicine: It’s a noble profession, it serves humanity.3
  4. 4. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 4 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.1.0 NERVOUS SYSTEM DISEASES: 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. 1.1 THE CENTRAL NERVOUS SYSTEM: Pict:1 Medicine: It’s a noble profession, it serves humanity.4
  5. 5. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 5 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 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! Medicine: It’s a noble profession, it serves humanity.5
  6. 6. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 6 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Different areas of your brain perform different functions:  Receive messages from sense organs  Interpreting images from the eye  Controls balance and muscle coordination  Thoughts and creativity  In charge of speech and reading  Basis of perception  In charge of feeling emotion  Initiates activity in the glands and muscles  Basic motor skills  Is the seat of consciousness, memory, reason and judgment  Figuring complex calculations  Regulates circulation and respiration 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. Medicine: It’s a noble profession, it serves humanity.6
  7. 7. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 7 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Pict:4 Pict:5 Medicine: It’s a noble profession, it serves humanity.7
  8. 8. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 8 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 1.1.2 THE SPINAL CORD: 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. Thats 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 Medicine: It’s a noble profession, it serves humanity.8
  9. 9. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 9 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 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 Medicine: It’s a noble profession, it serves humanity.9
  10. 10. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 10 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 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. Medicine: It’s a noble profession, it serves humanity.10
  11. 11. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 11 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 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 Medicine: It’s a noble profession, it serves humanity.11
  12. 12. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 12 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.2.0 SPINAL CORD TRAUMA: 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 Medicine: It’s a noble profession, it serves humanity.12
  13. 13. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 13 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 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. Medicine: It’s a noble profession, it serves humanity.13
  14. 14. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 14 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 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 doesnt 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 Medicine: It’s a noble profession, it serves humanity.14
  15. 15. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 15 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 2.3 CERVICAL (NEAR THE NECK) INJURIES: When spinal cord injuries occur near the neck shown in Pict:15, symptoms can affect both the arms and the legs:  Breathing difficulties (from paralysis of the breathing muscles)  Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms)  Numbness  Sensory changes  Spasticity (increased muscle tone)  Pain  Weakness, paralysis Pict:15 2.4 THORACIC (CHEST-LEVEL) INJURIES: Medicine: It’s a noble profession, it serves humanity.15
  16. 16. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 16 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. When spinal injuries occur at chest level, symptoms can affect the legs: Breathing difficulties (from paralysis of the breathing muscles) Loss of normal bowel and bladder control shown in Pict:16 (may include constipation, incontinence, bladder spasms) Numbness Sensory changes Spasticity (increased muscle tone) Pain Weakness, paralysis 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 Medicine: It’s a noble profession, it serves humanity.16
  17. 17. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 17 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 2.5 LUMBAR SACRAL SHOWN IN PICT:17 (LOWER-BACK) INJURIES: 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 The following tests may be ordered:  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. Medicine: It’s a noble profession, it serves humanity.17
  18. 18. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 18 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Pict:18 Pict:19 Medicine: It’s a noble profession, it serves humanity.18
  19. 19. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 19 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Pict:20 Pict:21 Medicine: It’s a noble profession, it serves humanity.19
  20. 20. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 20 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 2.6 PHYSICAL THERAPY FOR SPINAL CORD INJURY: 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 RESPIRATORY CARE: When in the intensive care unit, physical therapists can help teach you how best to breath and cough using many hands-on techniques. They will also suction the mucous out of your lungs if necessary. A physical therapists purpose with respiratory care is to help you breathe easier and to decrease your chance of developing a lung infection such as pneumonia. Respiratory complications of spinal cord injury (SCI), including:  Atelectasis  Pneumonia  Respiratory failure  Pulmonary embolism  Pleural effusion  Sleep-disordered breathing A. MANAGEMENT: 1. Prevention and treatment of atelectasis and pneumonia.  Monitoring indicators  Intubation (for intractable respiratory failure, demonstrable aspiration, or high risk for aspiration plus respiratory compromise)  Specific tests of pulmonary mechanics and ventilation  Clearing the airway of secretions  Diaphragm fluoroscopy  Reexpansion of the affected lung tissue following successful treatment (required for atelectasis or pneumonia) 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 Medicine: It’s a noble profession, it serves humanity.20
  21. 21. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 21 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 3. Weaning from the ventilator.  Progressive ventilator-free breathing (PVFB)  Synchronized intermittent mandatory ventilation (SIMV)  Partial weaning 4. Evaluation for electrophrenic respiration 5. Polysomnographic evaluation 6. Positive airway pressure therapy (if sleep disordered breathing is diagnosed) 7. Evaluation for and prevention of dysphagia and aspiration 8. Tracheostomy (for patients who are aspirating) 9. Psychosocial assessment and treatment  Monitoring of patients post-injury feeling states  Assessment of substance abuse  Assessment of pain  Establishment of advance directives  Assistance and support of family caregivers  Addressing of intimacy and sexuality issues (with the patient and other appropriate parties)  Establishment of an effective communication system. B. DISCHARGE AND FOLLOW-UP: 1. Education of patient and caregivers 2. Evaluation and modification of patients home 3. Provision of appropriate medical equipment and personnel resources 4. Transportation assistance 5. Evaluation of financial resources and available benefits 6. Determining the availability of transition and leisure resources 7. Vocational evaluation 2.7 RANGE OF MOTION: 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. Medicine: It’s a noble profession, it serves humanity.21
  22. 22. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 22 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 2.7.1 INCREASED STRENGTH: 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.  Exercise has benefits beyond increasing strength. An exercise program designed by your physical therapist also improves coordination, endurance, and circulation. Your physical therapist will develop a program to meet your abilities, lifestyle, age, and specific goals for therapy.  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 2.8 MUSCLE STRENGTHENING: 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. Medicine: It’s a noble profession, it serves humanity.22
  23. 23. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 23 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 2.9 COORDINATION AND BALANCE EXERCISES: These exercises can help people who have problems with coordination and balance, usually because of a stroke or brain damage. Coordination exercises aim to help people do specific tasks. The exercises involve repeating a meaningful movement that works more than one joint and muscle, such as picking up an object or touching a body part. Balance exercises are initially done using parallel bars, with a therapist standing right behind the person. The person shifts weight between the right and left legs in a swaying motion. Once this exercise can be done safely, weight can be shifted forward and backward. When these exercises are mastered, the person can do them without parallel bars. Pict:24 Medicine: It’s a noble profession, it serves humanity.23
  24. 24. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 24 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 2.9.1 AMBULATION EXERCISES: Walking (ambulation)—independently or with assistance—may be the main goal of rehabilitation. Before starting ambulation exercises, people must be able to balance while standing. To improve balance, people usually hold onto parallel bars and shift weight from side to side and from front to back. To keep them safe, the therapist stands in front of or behind them. Some people need to improve a joints range of motion or muscle strength. Some people need an orthotic device such as a brace. See Pict:23 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. Medicine: It’s a noble profession, it serves humanity.24
  25. 25. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 25 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 2.9.2 GENERAL CONDITIONING EXERCISES: A combination of range-of-motion, muscle-strengthening, and ambulation exercises is used to counter the effects of prolonged bed rest or immobilization. General conditioning exercises help improve cardiovascular fitness (the ability of the heart, lungs, and blood vessels to deliver oxygen to working muscles), as well as maintain flexibility and muscle strength. Medicine: It’s a noble profession, it serves humanity.25
  26. 26. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 26 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 2.10 WHEELCHAIR SKILLS: 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. 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. 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 Tilt Table: 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 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. Medicine: It’s a noble profession, it serves humanity.26
  27. 27. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 27 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.3.0 HEAD INJURY: Few nonfatal injuries cause such devastating physical and psychological effects as trauma to the central nervous system. In many cases, irreversible damage occurs regardless of the care the victim receives. In a significant number of cases, however, the initial care administered determines the ultimate outcome of the case. In fact, in such "treatable" patients, the emergency management is frequently more important than all subsequent efforts. This statement should trigger in your mind the importance of your role in the evaluation and initial care of these patients. a. The most important initial indicator of the severity of a head injury is the patients level of consciousness. A competent observer should assess the patients 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 Medicine: It’s a noble profession, it serves humanity.27
  28. 28. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 28 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 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. 3.1.1 HEAD INJURY: See: Pict:30 The words "head injury" usually refer to an injury to the portion of the skull (cranium) that encloses the brain, the overlying scalp, or the contents of the cranial cavity (brain, cranial nerves, meninges, and associated blood vessels). This definition focuses attention on that portion of the head that is at or above the level of the eyebrows anteriorly, the zygomatic arches laterally, and an imaginary line between the tips of the mastoid processes posteriorly. These are approximate external landmarks for the skull base, which is the floor of the cranial cavity. Nevertheless, physical signs of injury of the brain or of its soft tissue or bony coverings may also be detected in adjacent structures of the head (eyes, ears, and nose) or even in portions of the body that are remote from it. 3.1.2 BRAIN INJURIES: Most brain injuries occur due to movement of the brain inside the skull. The level of damage to the brain depends on the speed the head was traveling and the heads position just prior to contact. Medicine: It’s a noble profession, it serves humanity.28
  29. 29. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 29 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 3.1.3 RESPONSES TO BRAIN INJURY:. The base of the skull is rough; therefore, movement over this area will cause various degrees of injury to the brain or blood vessels. Possible responses to brain injury include the following: a. Initial response to a bruised brain is swelling. The swelling is caused by:  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. c. Hyperventilation may occur, causing a decrease in the carbon dioxide, vasoconstriction, and better perfusion (passage of a fluid through the vessels of an organ) for the brain. 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. 32 d. Unconsciousness may occur due to injury to the cerebral cortex or the brain stem. See picture 32. Pict. 33. e. If there is increased intracranial pressure (ICP) and decreasing cerebral blood flow, no matter what the cause, the level of consciousness is depressed. Medicine: It’s a noble profession, it serves humanity.29
  30. 30. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 30 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 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 reciprocal decrease in volume of one or both of the others must occur. Otherwise, the result is an increase in intracranial pressure. 3.2 INTRACRANIAL PRESSURE (ICP): Pict:34 NOTE: Intracranial pressure monitoring is performed by inserting a catheter into the head with a sensing device to monitor the pressure around the brain. An increase in intracranial pressure can cause a decrease in blood flow to the brain causing brain damage. 3.2.1 CHANGES CAUSED BY INTRACRANIAL PRESSURE: 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. Medicine: It’s a noble profession, it serves humanity.30
  31. 31. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 31 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 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. Cushings 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 bodys 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 brains 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. 3.2.2 PROGRESSIVE LEVELS OF INTRACRANIAL PRESSURE: Three progressive levels of intracranial pressure can be identified. 1. Progressive level one. a. Involves cerebral cortex and upper brain stem. b. Blood pressure rises, pulse slows. c. Pupils appear small but are reactive. d. Abnormal respiratory pattern noted (possibly Cheyne-Stokes). e. Initially, patient will try to remove painful stimuli. Later, the patient withdraws from pain. f. As progression occurs, the pain will cause decorticate posturing (flexion of the upper extremities with lower extremities becoming rigid and extended). g. Still reversible. Medicine: It’s a noble profession, it serves humanity.31
  32. 32. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 32 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Pict:35 2. Progressive level two. a. Middle portion of the brain stem is involved. b. Blood pressure increases. c. Pulse slows. d. Pupils become fixed at 3 to 5 mm and nonreactive or only sluggishly reactive to light. e. Abnormal respiratory pattern: fast, shallow panting (neurogenic hyperventilation). Medicine: It’s a noble profession, it serves humanity.32
  33. 33. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 33 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Pict:36 3. Progressive level three. a. Pupils become fixed and dilated. b. If only one "blown" pupil, it will be on the same side as the hematoma or swelling. (Crossover of nerves occurs at about the lip level.) c. Document which pupil dilates first. d. Respiratory ataxia (erratic, no rhythm) or absent. No response to painful stimuli. e. Pulse is rapid and irregular. f. Decreased blood pressure. Medicine: It’s a noble profession, it serves humanity.33
  34. 34. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 34 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 3.2.3 ANOXIC BRAIN INJURY: Anoxic brain injury is injury to the brain from lack of oxygen (from cardiac arrest, choking, or drowning). Spasms develop in small arteries if the brain goes without oxygen for more than 4 to 6 minutes. Blood flow does not reach the cerebral cortex. The level of brain damage is based on the length of anoxia (lack of oxygen). See pict.37 Pict.38 Medicine: It’s a noble profession, it serves humanity.34
  35. 35. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 35 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.4.0. SPECIFIC TYPES OF HEAD INJURY: 4.1 SCALP WOUNDS: The scalp has many blood vessels, a number of which are close to the surface. A scalp laceration, therefore, may bleed profusely even though a major blood vessel has not been cut. Initially, even a minor laceration may bleed a great deal. Normally, blood in the scalp clots rapidly, and blood flow can be controlled easily. If necessary, bleeding can usually be controlled by direct pressure; that is, by compressing the scalp between the fingertips and the skull. It is important to control bleeding in both adults and children, but it is especially important in children because they have a smaller volume of blood. See picture 38. Pict: 39 Medicine: It’s a noble profession, it serves humanity.35
  36. 36. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:004 Revision: 01 Page: 36 of 52 MANAGEMENT OF CENTRAL NERVOUS SYSTEM TRAUMA AND DISEASENOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 4.2 SKULL INJURIES: The skull is composed of the cranium and the face. Skull fractures are commonly fractures to the cranium rather than the face. Pict:40 4.2.1 SIGNS/SYMPTOMS OF SKULL INJURIES: The most obvious signs of a skull fracture are visible bone fragments and bits of brain tissue. The possibility of a skull fracture exists when any of the following less obvious signs/symptoms are present: 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 patients head injury. d. There is a deformity of the patients skull; for example, a depression in the cranium, a large swelling, or anything that looks unusual about the craniums shape. e. The patient has a bruise or swelling behind the ear (Battles 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 patients 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. Medicine: It’s a noble profession, it serves humanity.36

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