neurological rehabilitation, physical therapy in encephalitis

1. Encephalitis

2. Introduction
 Encephalitis is an acute inflammation of the
parenchyma of brain & spinal cord
 Encephalitis with meningitis is known as
meningoencephalitis
Dr. L. Surbala (MPT Neurology)2

3. Epidemiology
 A rare disease occurring in approximately 0.5 per
100,000 individuals
 Most common in children, elderly, and people with
weakened immune systems (HIV/AIDS or cancer).
Dr. L. Surbala (MPT Neurology)3

4. Pathology
 Virus enters blood & reaches the parenchyma of
brain, cortex, white matter, basal ganglia & brainstem
 Inclusion bodies are often present in neurons & glial cells &
there is infiltration of polymorphonuclear cells in
perivascular space
 There is neuronal degeneration & diffuse glial proliferation
often associated with cerebral edema & increased ICP
 Thrombosis may occur in small arteries of brain
 Tonsilar herniation may also be seen due to raised ICP
Dr. L. Surbala (MPT Neurology)4

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 doesn't stop or that seems worse when an infant is picked up
or handled in some way
 body stiffness
Dr. L. Surbala (MPT Neurology)5

6.  In more severe cases
of encephalitis,
 high fever
 severe headache
 nausea and vomiting
 stiff neck
 confusion
 disorientation
 personality changes
 convulsions (seizures)
 problems with speech or
hearing
 hallucinations
 memory loss
 drowsiness
 coma
Dr. L. Surbala (MPT Neurology)6

7.  Encephalitis can follow or accompany common viral
illnesses,
 There are sometimes signs & symptoms of these
illnesses beforehand
 But often, encephalitis appears without warning.
Dr. L. Surbala (MPT Neurology)7

8. Contagiousness
 Brain inflammation itself is not contagious,
 Any viruses that cause encephalitis can be
infectious
Dr. L. Surbala (MPT Neurology)8

9. Causes
 Viral
 Other micro organisms
Dr. L. Surbala (MPT Neurology)9

10. Viral enchephalitis
 Viral encephalitis can be due to direct effects of acute
infection, or as sequelae of a latent infection.
 A common cause of encephalitis in humans is herpes simplex
virus 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), Western
equine encephalitis (WEE)
 Venezualen equine encephalitis (VEE).
Dr. L. Surbala (MPT Neurology)10

11. Herpesviral encephalitis
 Herpes simplex encephalitis (HSE) is a severe viral infection of
the human CNS
 It is estimated to affect at least 1 in 500,000 individuals per
year.
 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 50
years of ageDr. L. Surbala (MPT Neurology)11

12. Bacterial & others
 It can be caused by a bacterial infection, such as
bacterial meningitis, spreading directly to brain
(primary encephalitis), or may be a complication of a
current infectious disease syphilis (secondary
encephalitis)
 Certain parasitic or protozoal infestations, such as
toxoplasmosis, malaria, or primary amoebic
meningoencephalitis, can also cause encephalitis in
people with compromised immune systemsDr. L. Surbala (MPT Neurology)12

13. Limbic encephalitis
 Pathogens responsible for encephalitis attack primarily limbic
system, often causing memory deficits
 However, for 20% of people with the diagnosis of limbic
encephalitis 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 most
commonly associated with small cell lung carcinoma
 Whereas majority of encephalitides are viral in nature, PLE is
often associated with cancer
Dr. L. Surbala (MPT Neurology)13

14. Encephalitis lethargica
 It is an atypical form of encephalitis which caused an epidemic
from 1918 to 1930.
 Those who survived sank into a semi-conscious state that lasted
for decades until L-DOPA was used to revive those still alive in
the late 1960
 The cause is now thought to be either a bacterial agent or an
autoimmune response following infection.
 Also known as "sleepy sickness" or as "sleeping sickness"
 The disease attacks the brain, leaving some victims in a statue-like
condition, speechless and motionlessDr. L. Surbala (MPT Neurology)14

15. Duration & prognosis
 For most forms of encephalitis, acute phase of illness (when
symptoms are most severe) usually lasts up to a week
 Full recovery can take much longer, often several weeks or
months.
 Without treatment, HSE results in rapid death in
approximately 70% of cases
 HSE is fatal in around 20% of cases treated, and causes
serious long-term neurological damage in over half of survivors
Dr. L. Surbala (MPT Neurology)15

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 with
normal 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 a
specific viral agent (such as herpes simplex virus) or by polymerase
chain reaction that amplifies RNA or DNA of virus responsible (such
as varicella zoster virus).
Dr. L. Surbala (MPT Neurology)16

17. Prevention
 Encephalitis cannot be prevented except to try to prevent
causes that may lead to it
 Encephalitis that may be seen with common childhood illness can
be largely prevented through proper immunization
 Children should avoid contact with anyone who already has
encephalitis.
Dr. L. Surbala (MPT Neurology)17

18. Treatment
 Maintain fluid & nourishment
 Sedatives
 Corticosteroids
 Antibiotics & antiviral
 Anticonvulsions
Dr. L. Surbala (MPT Neurology)18

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.  Higher function:
 Level of consciousness: altered sensorium
 Orientation: confusion
 Memory: affected
 Speech: dysarthria , aphasia, mutism
 Cranial nerve assessment: features of lower cranial
nerve palsy will be seen
 Sensory system: impaired
 Tonal abnormalities will be seen
 Reflexes: exaggerated DTR, positive
barbinski’s, presence of abnormal lower level reflexes
(primitive reflexes)
Dr. L. Surbala (MPT Neurology)20

21.  ROM: decreased range & flexibility
 Strength: decreased
 Chest examination & Respiratory assessment:
accumulation of secretions, decreased chest
expansion or abnormal respiratory pattern may be
seen
 Gustatory examination: swallowing & speech
difficulty
Dr. L. Surbala (MPT Neurology)21

22.  Bladder & bowel involvement
 Functional disability
 Special test: kernig, brudjinski shows positive
response
 Investigations: blood & CSF examination, CT
or MRI, gram stain, serology shows abnormal
findings
 Problem listing
Dr. L. Surbala (MPT Neurology)22

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. Psychological support
 Maintain a non threatening positive attitude
 Good support
 Gain confidence of the patient
 Counseling of family members & patient
 Give information as necessary only
Dr. L. Surbala (MPT Neurology)24

25. Prevent chest complications
 Breathing exercise, postural drainage & suctioning as
required
 Cervical & thoraxic mobility exercise
 Thoraxic expansion exercise
 Strengthening of respiratory muscles
Dr. L. Surbala (MPT Neurology)25

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 exercise
Dr. L. Surbala (MPT Neurology)26

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 position
Dr. L. Surbala (MPT Neurology)27

28. Correct deformity
 Proper positioning
 If synergy is present, facilitation & inhibition
techniques
 Facilitatory tech
Vibration, stroking, joint approximation tech, quick
iceing, quick stretching etc
 Inhibitory tech
Sustained stretching, pressure, neural warmth, prolonged
iceing, joint traction
 Splinting & serial castingDr. L. Surbala (MPT Neurology)28

29. Promote vital function
 Improve respiratory capacity with positioning & tech s/a
glossopharyngeal breathing exercise in respiratory
paralysis
 Keeping the neck in slight flexion improves respiratory
capacity
 Specific positioning increase air entry in targeted lobes
 Massage & mechanical pressure provides reflex stimulus to
improve peristalsis (kneading/ stroking)
 Facilitate swallowing with positioning, right selection of
food texture, oromotor stimulation
 Maintaining cardio respiratory endurance with active
exercise of possible muscle work
Dr. L. Surbala (MPT Neurology)29

30. Normalize tone
 Facilitatory & inhibitory techniques
Dr. L. Surbala (MPT Neurology)30

31. Promote integration of sensory
input
 Stimulation by combined proprioceptive, visual &
auditory input
 Cues & commands
 Demonstration of activity
 Sensory re education if necessary
 Training in different environment
Dr. L. Surbala (MPT Neurology)31

32. Promote voluntary movement
pattern
 Open kinematic chain exercise to improve mobility
 Close kinematic chain exercise to improve stability
 Transfer techniques
 Including functional challenges
 Problem solving task
Dr. L. Surbala (MPT Neurology)32

33. Improve overall function
 Maintenance of physical activity
 Maintenance of CV endurance
 Early Return to activity or work
Dr. L. Surbala (MPT Neurology)33