Encephalitis: PT assessment and management

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neurological rehabilitation, physical therapy in encephalitis

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Encephalitis: PT assessment and management

  1. 1. Encephalitis
  2. 2. Introduction Encephalitis is an acute inflammation of theparenchyma of brain & spinal cord Encephalitis with meningitis is known asmeningoencephalitisDr. L. Surbala (MPT Neurology)2
  3. 3. Epidemiology A rare disease occurring in approximately 0.5 per100,000 individuals Most common in children, elderly, and people withweakened immune systems (HIV/AIDS or cancer).Dr. L. Surbala (MPT Neurology)3
  4. 4. Pathology Virus enters blood & reaches the parenchyma ofbrain, cortex, white matter, basal ganglia & brainstem Inclusion bodies are often present in neurons & glial cells &there is infiltration of polymorphonuclear cells inperivascular space There is neuronal degeneration & diffuse glial proliferationoften associated with cerebral edema & increased ICP Thrombosis may occur in small arteries of brain Tonsilar herniation may also be seen due to raised ICPDr. L. Surbala (MPT Neurology)4
  5. 5. Signs & symptoms Symptoms in milder cases of encephalitis usually include: fever headache poor appetite weakness a general sick feeling In infants, important signs include: vomiting a full or bulging fontanel crying that doesnt stop or that seems worse when an infant is picked upor handled in some way body stiffnessDr. L. Surbala (MPT Neurology)5
  6. 6.  In more severe casesof encephalitis, high fever severe headache nausea and vomiting stiff neck confusion disorientation personality changes convulsions (seizures) problems with speech orhearing hallucinations memory loss drowsiness comaDr. L. Surbala (MPT Neurology)6
  7. 7.  Encephalitis can follow or accompany common viralillnesses, There are sometimes signs & symptoms of theseillnesses beforehand But often, encephalitis appears without warning.Dr. L. Surbala (MPT Neurology)7
  8. 8. Contagiousness Brain inflammation itself is not contagious, Any viruses that cause encephalitis can beinfectiousDr. L. Surbala (MPT Neurology)8
  9. 9. Causes Viral Other micro organismsDr. L. Surbala (MPT Neurology)9
  10. 10. Viral enchephalitis Viral encephalitis can be due to direct effects of acuteinfection, or as sequelae of a latent infection. A common cause of encephalitis in humans is herpes simplexvirus type I (HSE) Others include infection by Flaviviruses such as St. Louis encephalitis or West Nile virus, or Togaviruses such as Eastern equine encephalitis (EEE), Westernequine encephalitis (WEE) Venezualen equine encephalitis (VEE).Dr. L. Surbala (MPT Neurology)10
  11. 11. Herpesviral encephalitis Herpes simplex encephalitis (HSE) is a severe viral infection ofthe human CNS It is estimated to affect at least 1 in 500,000 individuals peryear. About 1 in 3 cases of HSE result from primary HSV-1 infection, predominantly occurring in individuals under age of 18; 2 in 3 cases occur in seropositive persons, few of whom have history of recurrent orofacial herpes Approximately 50% of individuals that develop HSE are over 50years of ageDr. L. Surbala (MPT Neurology)11
  12. 12. Bacterial & others It can be caused by a bacterial infection, such asbacterial meningitis, spreading directly to brain(primary encephalitis), or may be a complication of acurrent infectious disease syphilis (secondaryencephalitis) Certain parasitic or protozoal infestations, such astoxoplasmosis, malaria, or primary amoebicmeningoencephalitis, can also cause encephalitis inpeople with compromised immune systemsDr. L. Surbala (MPT Neurology)12
  13. 13. Limbic encephalitis Pathogens responsible for encephalitis attack primarily limbicsystem, often causing memory deficits However, for 20% of people with the diagnosis of limbicencephalitis an MRI will not show any neurological abnormalities 60% of the time, limbic encephalitis is paraneoplastic in origin. A severe form of limbic encephalitis caused by neoplasms mostcommonly associated with small cell lung carcinoma Whereas majority of encephalitides are viral in nature, PLE isoften associated with cancerDr. L. Surbala (MPT Neurology)13
  14. 14. Encephalitis lethargica It is an atypical form of encephalitis which caused an epidemicfrom 1918 to 1930. Those who survived sank into a semi-conscious state that lastedfor decades until L-DOPA was used to revive those still alive inthe late 1960 The cause is now thought to be either a bacterial agent or anautoimmune response following infection. Also known as "sleepy sickness" or as "sleeping sickness" The disease attacks the brain, leaving some victims in a statue-likecondition, speechless and motionlessDr. L. Surbala (MPT Neurology)14
  15. 15. Duration & prognosis For most forms of encephalitis, acute phase of illness (whensymptoms are most severe) usually lasts up to a week Full recovery can take much longer, often several weeks ormonths. Without treatment, HSE results in rapid death inapproximately 70% of cases HSE is fatal in around 20% of cases treated, and causesserious long-term neurological damage in over half of survivorsDr. L. Surbala (MPT Neurology)15
  16. 16. Diagnosis Neurological examinations reveal a drowsy or confused patient Stiff neck, may indicate meningoncephalitis CSF : varies from normal to increased amounts of protein & WBC withnormal glucose EEG may show sharp waves in one or both of temporal lobes. CT scan examination to exclude brain swelling before Lumbar puncture Diagnosis is made with detection of antibodies in CSF against aspecific viral agent (such as herpes simplex virus) or by polymerasechain reaction that amplifies RNA or DNA of virus responsible (suchas varicella zoster virus).Dr. L. Surbala (MPT Neurology)16
  17. 17. Prevention Encephalitis cannot be prevented except to try to preventcauses that may lead to it Encephalitis that may be seen with common childhood illness canbe largely prevented through proper immunization Children should avoid contact with anyone who already hasencephalitis.Dr. L. Surbala (MPT Neurology)17
  18. 18. Treatment Maintain fluid & nourishment Sedatives Corticosteroids Antibiotics & antiviral AnticonvulsionsDr. L. Surbala (MPT Neurology)18
  19. 19. PT assessment Presenting complains: Headache, nausea, vomiting, fever,convulsions, confusion, abnormal movements History: preceding infection, general weakness, frequent headache Vitals: BP, PR, RR, Temperature abnormalities may be noted Observation: Posture; abnormal posturing Gait: abnormalities (may be ataxic) Limb attitude: abnormal attitude (synergies) Abnormal Respiratory patternDr. L. Surbala (MPT Neurology)19
  20. 20.  Higher function: Level of consciousness: altered sensorium Orientation: confusion Memory: affected Speech: dysarthria , aphasia, mutism Cranial nerve assessment: features of lower cranialnerve palsy will be seen Sensory system: impaired Tonal abnormalities will be seen Reflexes: exaggerated DTR, positivebarbinski’s, presence of abnormal lower level reflexes(primitive reflexes)Dr. L. Surbala (MPT Neurology)20
  21. 21.  ROM: decreased range & flexibility Strength: decreased Chest examination & Respiratory assessment:accumulation of secretions, decreased chestexpansion or abnormal respiratory pattern may beseen Gustatory examination: swallowing & speechdifficultyDr. L. Surbala (MPT Neurology)21
  22. 22.  Bladder & bowel involvement Functional disability Special test: kernig, brudjinski shows positiveresponse Investigations: blood & CSF examination, CTor MRI, gram stain, serology shows abnormalfindings Problem listingDr. L. Surbala (MPT Neurology)22
  23. 23. PT aims Psychological support Prevent chest complications Prevent DVT Prevent bed sores Correct deformity Promote vital function Normalize tone Normalise postural reflexes Promote integration of sensory input Promote voluntary movement pattern Improve overall functionDr. L. Surbala (MPT Neurology)23
  24. 24. Psychological support Maintain a non threatening positive attitude Good support Gain confidence of the patient Counseling of family members & patient Give information as necessary onlyDr. L. Surbala (MPT Neurology)24
  25. 25. Prevent chest complications Breathing exercise, postural drainage & suctioning asrequired Cervical & thoraxic mobility exercise Thoraxic expansion exercise Strengthening of respiratory musclesDr. L. Surbala (MPT Neurology)25
  26. 26. Prevent DVT Active & passive ankle & toe exercise Active limb exercise Limb elevation Early mobilization as soon as possible Propped up position in bed & bed mobility exerciseDr. L. Surbala (MPT Neurology)26
  27. 27. Prevent bed sores Proper positioning with pads & cushions Use of water bed or foam mattress Regular inspection of the skin Use cotton clothing to absorb sweat Avoid dragging during transfer Regular turning & changing positionDr. L. Surbala (MPT Neurology)27
  28. 28. Correct deformity Proper positioning If synergy is present, facilitation & inhibitiontechniques Facilitatory techVibration, stroking, joint approximation tech, quickiceing, quick stretching etc Inhibitory techSustained stretching, pressure, neural warmth, prolongediceing, joint traction Splinting & serial castingDr. L. Surbala (MPT Neurology)28
  29. 29. Promote vital function Improve respiratory capacity with positioning & tech s/aglossopharyngeal breathing exercise in respiratoryparalysis Keeping the neck in slight flexion improves respiratorycapacity Specific positioning increase air entry in targeted lobes Massage & mechanical pressure provides reflex stimulus toimprove peristalsis (kneading/ stroking) Facilitate swallowing with positioning, right selection offood texture, oromotor stimulation Maintaining cardio respiratory endurance with activeexercise of possible muscle workDr. L. Surbala (MPT Neurology)29
  30. 30. Normalize tone Facilitatory & inhibitory techniquesDr. L. Surbala (MPT Neurology)30
  31. 31. Promote integration of sensoryinput Stimulation by combined proprioceptive, visual &auditory input Cues & commands Demonstration of activity Sensory re education if necessary Training in different environmentDr. L. Surbala (MPT Neurology)31
  32. 32. Promote voluntary movementpattern Open kinematic chain exercise to improve mobility Close kinematic chain exercise to improve stability Transfer techniques Including functional challenges Problem solving taskDr. L. Surbala (MPT Neurology)32
  33. 33. Improve overall function Maintenance of physical activity Maintenance of CV endurance Early Return to activity or workDr. L. Surbala (MPT Neurology)33

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