Motor and Neurological Impairments on Clients

1. MOTOR AND NEUROLOGICAL
IMPAIRMENTS
Prepared by: JENNIFER B. GARCIA, RN

2. Main issues: mobility, communication, breathing
Amyotrophic Lateral Sclerosis (ALS), also called Lou Gehrig’s disease or motor neuron disease, is a
progressive, neuromuscular disease that attacks nerve cells and pathways in the brain and spinal cord.
Motor neurons, among the largest of all nerve cells, reach from the brain to the spinal cord and from the
spinal cord to muscles throughout the body.When these motor neurons die, the brain can no longer start
and control muscle movement.
Amyotrophic comes from the Greek language. “A” means no or negative. “Myo” refers to muscle, and
“trophic” means nourishment, thus “no muscle nourishment.”When a muscle receives no nourishment, it
atrophies or wastes away.
“Lateral” identifies the areas in a person's spinal cord where portions of the nerve cells that nourish the
muscles are located. As this area degenerates, it leads to scarring or hardening (“sclerosis”) in the region.
Amyotrophic Lateral Sclerosis:

3. As more and more nerves and muscles are
affected, the person with ALS loses the ability
to move, eventually suffering complete
paralysis.The muscles used for breathing,
speaking, and swallowing also become
affected.
ALS does not affect the person’s mind, senses
(feeling, tasting, smelling etc.), bladder and
bowel function, or sexual drive and function. As
muscle cells deteriorate, patients may
experience stiffness, occasional jerking of the
arms or legs, or twitching (fasciculations). Often
symptoms begin in the hands and feet, then
travel inward toward the center of the body.
One side is usually more affected than the
other. Eventually paralysis may be complete,
except for the muscles of the eyes.

5. Diagnosis
Amyotrophic lateral sclerosis is difficult to diagnose early because it can mimic other neurological diseases.Tests
to rule out other conditions might include:
1. Electromyogram (EMG).Your doctor inserts a needle electrode through your skin into various muscles.The
test evaluates the electrical activity of your muscles when they contract and when they're at rest.
Abnormalities in muscles seen in an EMG can help doctors diagnose or rule out ALS. An EMG can also help guide
your exercise therapy.
2. Nerve conduction study.This study measures your nerves' ability to send impulses to muscles in different
areas of your body.This test can determine if you have nerve damage or certain muscle or nerve diseases.
3. MRI. Using radio waves and a powerful magnetic field, an MRI produces detailed images of your brain and
spinal cord. An MRI can reveal spinal cord tumors, herniated disks in your neck or other conditions that might be
causing your symptoms.
4. Blood and urine tests. Analyzing samples of your blood and urine in the laboratory might help your doctor
eliminate other possible causes of your signs and symptoms.
5. Spinal tap (lumbar puncture).This involves removing a sample of your spinal fluid for laboratory testing using
a small needle inserted between two vertebrae in your lower back.
6. Muscle biopsy. If your doctor believes you may have a muscle disease rather than ALS, you might undergo a
muscle biopsy.While you're under local anesthesia, a small portion of your muscle is removed and sent to a lab
for analysis.

6. Treatment
Treatments can't reverse the damage of amyotrophic lateral sclerosis, but they can
slow the progression of symptoms, prevent complications, and make you more
comfortable and independent.
You might need an integrated team of doctors trained in many areas and other health
care professionals to provide your care.This might prolong your survival and improve
your quality of life.
Your team will help you select the right treatments for you.You have the right to
choose or refuse any of the treatments suggested.

7. Medications
The Food and Drug Administration has approved three medicines for treating ALS:
Riluzole (Rilutek, Exservan,Tiglutik kit).Taken orally, this medicine can increase life
expectancy by 3 to 6 months. It can cause side effects such as dizziness, gastrointestinal
conditions and liver function changes.Your health care provider will monitor your blood counts
and liver function while you're taking the medicine.
Edaravone (Radicava). This medicine, given through a vein in your arm or orally as a pill, can
reduce the decline in daily functioning. Its effect on life span isn't yet known. Side effects can
include bruising, headache and shortness of breath.This medicine is given daily for two weeks a
month.
Sodium phenylbutyrate and taurursodiol (Relyvrio).This medicine, recently approved by
the FDA, can slow the rate of decline in people withALS. In particular, it may help people with
performing daily tasks. It also may help people with ALS live longer, but more study is needed.
Potential side effects of the medicine include diarrhea, belly pain, nausea and upper respiratory
infection. People with disorders that affect bile acid circulation may experience diarrhea that
gets worse when taking this medicine.

8. Therapies
Breathing care.You'll eventually have more difficulty breathing
as your muscles weaken. Doctors might test your breathing
regularly and provide you with devices to assist your breathing
at night.
You can choose mechanical ventilation to help you breathe.
Doctors insert a tube in a surgically created hole at the front of
your neck leading to your windpipe (tracheostomy) that
connects to a respirator.
Physical therapy. A physical therapist can address pain, walking,
mobility, bracing and equipment needs that help you stay
independent. Practicing low-impact exercises can help maintain
your cardiovascular fitness, muscle strength and range of motion
for as long as possible.
Regular exercise can also help improve your sense of well-being.
Appropriate stretching can help prevent pain and help your
muscles function at their best.
A physical therapist can also help you adjust to a brace, walker or
wheelchair and might suggest devices such as ramps that make
it easier for you to get around.
Occupational therapy. An occupational therapist can help you
find ways to remain independent despite hand and arm
weakness. Adaptive equipment can help you perform activities
such as dressing, grooming, eating and bathing.
An occupational therapist can also help you modify your home
to allow accessibility if you have trouble walking safely.
•Speech therapy. A speech therapist can teach you adaptive
techniques to make your speech more understandable. Speech
therapists can also help you explore other methods of
communication, such as an alphabet board or pen and paper.
•Ask your therapist about the possibility of borrowing or renting
devices such as tablet computers with text-to-speech applications
or computer-based equipment with synthesized speech that can
help you communicate.
•Nutritional support.Your team will work with you and your family
members to ensure you're eating foods that are easier to swallow
and meet your nutritional needs.You might eventually need a
feeding tube.
•Psychological and social support.Your team might include a
social worker to help with financial issues, insurance, and getting
equipment and paying for devices you need. Psychologists, social
workers and others may provide emotional support for you and
your family.

9. Cerebrovascular Accident (CVA or commonly known as stroke):
Main issues: paralysis or weakness, vision problems, communication, emotional, depression
Ischemic stroke: Caused by a blockage in an artery, is responsible for about 85% of all strokes.The most
common ischemic stroke subtypes are:
 Thrombotic stroke: A blood clot (thrombus) forms in an artery in the neck or brain.These arteries
may have a build-up of fatty deposits called plaques.
 Embolic stroke: A blockage caused by blood clots that form elsewhere in the body (usually the heart)
and travel to the brain.A common source is an abnormal rhythm in the heart's two upper chambers
(atrial fibrillation), which may cause clots to form.
 Hemorrhagic stroke: Hemorrhage means bleeding.This type of stroke is caused by a leak or rupture
of an artery in the brain or on its surface. Such ruptures can be caused by an aneurysm (a thin, weak
area on an artery wall) or by a malformation of the brain's blood vessel system. Hemorrhages may
occur within the brain itself, or in the space between the brain and its protective outer layer.
Approximately 15% of all strokes are caused by hemorrhage.

10. Symptoms
If you or someone you're with may be having a stroke, pay particular attention to the time the symptoms
began. Some treatment options are most effective when given soon after a stroke begins.
Signs and symptoms of stroke include:
Trouble speaking and understanding what others are saying.You may experience confusion, slur words or
have difficulty understanding speech.
Paralysis or numbness of the face, arm or leg.You may develop sudden numbness, weakness or paralysis in
the face, arm or leg.This often affects just one side of the body.Try to raise both your arms over your head at
the same time. If one arm begins to fall, you may be having a stroke. Also, one side of your mouth may droop
when you try to smile.
Problems seeing in one or both eyes.You may suddenly have blurred or blackened vision in one or both
eyes, or you may see double.
Headache. A sudden, severe headache, which may be accompanied by vomiting, dizziness or altered
consciousness, may indicate that you're having a stroke.
Trouble walking.You may stumble or lose your balance.You may also have sudden dizziness or a loss of
coordination.

11. When to see a doctor
Seek immediate medical attention if you notice any signs or symptoms of a stroke, even if they seem
to come and go or they disappear completely.Think "FAST" and do the following:
Face.Ask the person to smile. Does one side of the face droop?
Arms. Ask the person to raise both arms. Does one arm drift downward? Or is one arm unable to rise?
Speech. Ask the person to repeat a simple phrase. Is his or her speech slurred or strange?
Time. If you observe any of these signs, call 911 or emergency medical help immediately.
Call 911 or your local emergency number right away. Don't wait to see if symptoms stop. Every minute
counts.The longer a stroke goes untreated, the greater the potential for brain damage and disability.
If you're with someone you suspect is having a stroke, watch the person carefully while waiting for
emergency assistance.

12. Causes
There are two main causes of stroke: a blocked artery (ischemic stroke) or leaking or bursting of a blood
vessel (hemorrhagic stroke). Some people may have only a temporary disruption of blood flow to the
brain, known as a transient ischemic attack (TIA), that doesn't cause lasting symptoms.
1. Ischemic stroke
This is the most common type of stroke. It happens when the brain's blood vessels become narrowed or
blocked, causing severely reduced blood flow (ischemia). Blocked or narrowed blood vessels are caused
by fatty deposits that build up in blood vessels or by blood clots or other debris that travel through the
bloodstream, most often from the heart, and lodge in the blood vessels in the brain.
Some initial research shows that COVID-19 infection may increase the risk of ischemic stroke, but more
study is needed.

14. 2. Hemorrhagic stroke
Hemorrhagic stroke occurs when a blood vessel in the brain leaks or ruptures. Brain hemorrhages can
result from many conditions that affect the blood vessels. Factors related to hemorrhagic stroke
include:
-Uncontrolled high blood pressure
-Overtreatment with blood thinners (anticoagulants)
-Bulges at weak spots in your blood vessel walls (aneurysms)
-Trauma (such as a car accident)
-Protein deposits in blood vessel walls that lead to weakness in the vessel wall (cerebral amyloid
angiopathy)
Ischemic stroke leading to hemorrhage
A less common cause of bleeding in the brain is the rupture of an irregular tangle of thin-walled blood
vessels (arteriovenous malformation).

15. Transient ischemic attack (TIA)
A transient ischemic attack (TIA) — sometimes known as a ministroke — is a temporary period
of symptoms similar to those in a stroke. ATIA doesn't cause permanent damage.ATIA is
caused by a temporary decrease in blood supply to part of the brain, which may last as little as
five minutes.
Like an ischemic stroke, aTIA occurs when a clot or debris reduces or blocks blood flow to part
of the nervous system.
Seek emergency care even if you think you've had aTIA because your symptoms got better. It's
not possible to tell if you're having a stroke orTIA based only on the symptoms. If you've had
aTIA, it means you may have a partially blocked or narrowed artery leading to the brain.
Having aTIA increases your risk of having a full-blown stroke later.

16. Risk factors
Many factors can increase the risk of stroke. Potentially treatable stroke risk factors include:
Lifestyle risk factors
Being overweight or obese
Physical inactivity
Heavy or binge drinking
Use of illegal drugs such as cocaine and methamphetamine
Medical risk factors
High blood pressure
Cigarette smoking or secondhand smoke exposure
High cholesterol
Diabetes
Obstructive sleep apnea
Cardiovascular disease, including heart failure, heart defects, heart infection or irregular heart rhythm, such
as atrial fibrillation
Personal or family history of stroke, heart attack or transient ischemic attack
COVID-19 infection

17. Other factors associated with a higher risk of stroke include:
Age — People age 55 or older have a higher risk of stroke than do younger people.
Race or ethnicity —African Americans and Hispanics have a higher risk of stroke than
do people of other races or ethnicities.
Sex — Men have a higher risk of stroke than do women.Women are usually older when
they have strokes, and they're more likely to die of strokes than are men.
Hormones — Use of birth control pills or hormone therapies that include estrogen
increases risk.

18. Complications
A stroke can sometimes cause temporary or permanent disabilities, depending on how long the brain
lacks blood flow and which part is affected. Complications may include:
Paralysis or loss of muscle movement.You may become paralyzed on one side of the body, or lose
control of certain muscles, such as those on one side of the face or one arm.
Difficulty talking or swallowing. A stroke might affect control of the muscles in the mouth and throat,
making it difficult for you to talk clearly, swallow or eat.You also may have difficulty with language,
including speaking or understanding speech, reading, or writing.
Memory loss or thinking difficulties. Many people who have had strokes experience some memory
loss.Others may have difficulty thinking, reasoning, making judgments and understanding concepts.
Emotional problems. People who have had strokes may have more difficulty controlling their emotions,
or they may develop depression.
Pain. Pain, numbness or other unusual sensations may occur in the parts of the body affected by stroke.
For example, if a stroke causes you to lose feeling in the left arm, you may develop an uncomfortable
tingling sensation in that arm.
Changes in behavior and self-care ability. People who have had strokes may become more withdrawn.
They may need help with grooming and daily chores.

19. Prevention
Knowing your stroke risk factors, following your health care provider's recommendations and adopting a
healthy lifestyle are the best steps you can take to prevent a stroke. If you've had a stroke or a transient
ischemic attack (TIA), these measures might help prevent another stroke.The follow-up care you receive in the
hospital and afterward also may play a role.
Many stroke prevention strategies are the same as strategies to prevent heart disease. In general, healthy
lifestyle recommendations include:
Controlling high blood pressure (hypertension).This is one of the most important things you can do to
reduce your stroke risk. If you've had a stroke, lowering your blood pressure can help prevent a
subsequentTIA or stroke. Healthy lifestyle changes and medications are often used to treat high blood
pressure.
Lowering the amount of cholesterol and saturated fat in your diet. Eating less cholesterol and fat, especially
saturated fat and trans fats, may reduce buildup in the arteries. If you can't control your cholesterol through
dietary changes alone, your doctor may prescribe a cholesterol-lowering medication.
Quitting tobacco use. Smoking raises the risk of stroke for smokers and nonsmokers exposed to secondhand
smoke. Quitting tobacco use reduces the risk of stroke.
Managing diabetes. Diet, exercise and losing weight can help you keep your blood sugar in a healthy range. If
lifestyle factors don't seem to be enough to control your diabetes, your doctor may prescribe diabetes
medication.

20. Maintaining a healthy weight. Being overweight contributes to other stroke risk factors, such as high blood
pressure, cardiovascular disease and diabetes.
Eating a diet rich in fruits and vegetables. A diet containing five or more daily servings of fruits or vegetables
may reduce the risk of stroke.The Mediterranean diet, which emphasizes olive oil, fruit, nuts, vegetables and
whole grains, may be helpful.
Exercising regularly. Aerobic exercise reduces the risk of stroke in many ways. Exercise can lower blood
pressure, increase the levels of good cholesterol, and improve the overall health of the blood vessels and heart.
It also helps you lose weight, control diabetes and reduce stress. Gradually work up to at least 30 minutes of
moderate physical activity — such as walking, jogging, swimming or bicycling — on most, if not all, days of the
week.
Drinking alcohol in moderation, if at all. Heavy alcohol consumption increases the risk of high blood pressure,
ischemic strokes and hemorrhagic strokes. Alcohol may also interact with other drugs you're taking. However,
drinking small to moderate amounts of alcohol, such as one drink a day, may help prevent ischemic stroke and
decrease the blood's clotting tendency.Talk to your doctor about what's appropriate for you.
Treating obstructive sleep apnea (OSA).Your doctor may recommend a sleep study if you have symptoms
of OSA — a sleep disorder that causes you to stop breathing for short periods repeatedly during sleep.
Treatment for OSA includes a device that delivers positive airway pressure through a mask to keep the airway
open while you sleep.
Avoiding illegal drugs. Certain street drugs, such as cocaine and methamphetamine, are established risk
factors for aTIA or a stroke.

21. Preventive medications
If you've had an ischemic stroke or aTIA, your doctor may recommend medications to help reduce your risk of
having another stroke.These include:
Anti-platelet drugs. Platelets are cells in the blood that form clots. Anti-platelet drugs make these cells less
sticky and less likely to clot.The most commonly used anti-platelet medication is aspirin.Your doctor can help
you determine the right dose of aspirin for you.
After aTIA or minor stroke, your doctor may give you aspirin and an anti-platelet drug such as clopidogrel
(Plavix) for a period of time to reduce the risk of another stroke. If you can't take aspirin, your doctor may
prescribe clopidogrel alone.
Anticoagulants.These drugs reduce blood clotting. Heparin is fast acting and may be used short-term in the
hospital.
Slower-acting warfarin (Jantoven) may be used over a longer term.Warfarin is a powerful blood-thinning drug,
so you'll need to take it exactly as directed and watch for side effects.You'll also need to have regular blood
tests to monitor warfarin's effects.
Several newer blood-thinning medications (anticoagulants) are available for preventing strokes in people who
have a high risk.These medications include dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis) and
edoxaban (Savaysa).They're shorter acting than warfarin and usually don't require regular blood tests or
monitoring by your doctor.These drugs are also associated with a lower risk of bleeding complications
compared to warfarin.

22. Parkinson’s Disease:
Main issues: tremor, rigidity, walking, balance, bradykinesia/akinesia
Parkinson’s disease (PD) is a progressive, neurological disease that mainly affects movement but can also affect
cognition. Parkinson’s disease results from the destruction of nerve cells in a part of the brain called the basal ganglia.
Different parts of the brain work together by sending signals to each other to coordinate all of our thoughts,
movements, emotions, and senses. When we want to move, a signal is sent from the basal ganglia to the thalamus
and then to the cerebral cortex, all different parts of the brain. Nerve cells in the brain communicate by using
chemicals. A chemical (neurotransmitter) called dopamine is produced in a group of cells called the substantia nigra
and is essential for normal movement.
When the cells die, they can no longer produce and send dopamine, so the signal to move doesn’t get communicated.
By the time a person starts to experience motor symptoms of Parkinson’s, they’ve already lost approximately 50% of
their dopamine producing cells. People may experience non-motor symptoms from loss of other neurotransmitters up
to ten years before motor symptoms are noticed.

24. Main issues: tremors, swallowing, incontinence, fatigue, coordination, vision
MS is an autoimmune disorder of the central nervous system. Scientifically speaking, in
someone with MS, the body starts to attack the myelin sheath, the special protective
membrane coating the spinal cord and nerve endings.
The myelin sheath is responsible for helping signals being sent back and forth between the
brain and the body get to where they need to go quickly and efficiently.
As MS progresses, the myelin sheath starts to break down and problems happen with the
signals. Nerve fibers become damaged and die off, lesions can grow on the brain, and spinal
cord and bodily functions are affected.
Multiple Sclerosis:

26. Alzheimer’s disease:
Main issues: memory, attention, forgetfulness, withdrawal, behavioral, communication, coordination, personal care,
incontinence, eating
Alzheimerʼs disease (AD) is a condition that causes abnormal changes in the brain mainly affecting memory and other
mental abilities. Alzheimerʼs is a disease, not a normal part of aging.
Loss of memory is the usual first symptom. As the disease progresses, the loss of reasoning ability, language, decision-
making ability, judgment, and other critical skills make navigating day-to-day living impossible without help from others,
most often a family member or friend. Sometimes, but not always, difficult changes in personality and behavior occur.
Although the cause and progression of AD are not fully understood, increasing evidence shows that the first changes in
the brain happen as much as 15 years before symptoms of dementia are exhibited by the person with AD. Certain kinds of
brain scans can detect these changes. However, this work is not yet advanced enough for it to be of practical use in
predicting who will later develop Alzheimerʼs disease.

28. Cerebral Palsy:
Main issues: coordination, posture, movement, balance, muscle tone/control, eating
Also known as CP, this is a physical disability that affects movement and posture. It is an umbrella
term that refers to a group of disorders affecting a person’s ability to move. It is a permanent life-
long condition but generally does not worsen over time.
It is due to damage to the developing brain either during pregnancy or shortly after birth.
CP affects people in different ways and can affect body movement, muscle control, muscle
coordination, muscle tone, relax, posture, and balance.The cause is unknown. Some considerations
are insufficient oxygen (problems with placenta or umbilical cord in utero, or difficult/delayed
delivery), maternal infection during pregnancy, low birth weight, or maternal blood group
incompatibility.

29. There are 4 types:
1. Spastic: Characterized by stiffness and contractions
of muscles.
2. Athetoid/dyskinetic: slow, writhing, uncontrolled
movements.
3. Ataxic: Lack of coordination and muscle tone.
Balance difficulties.
4.Mixed: More than one area of the brain is affected,
so several types might be present.

30. Traumatic Brain Injury:
Main Issues: cognitive, behavioral, emotional, speech, weakness, coordination,
senses, sleep
Referred to as a TBI, traumatic brain injury (head injury) occurs when a jolt or blow to
the head causes damage to the brain. Bruising, lack of oxygen to an area of the brain,
or broken neurons (as a result of shaking) occur and cause damage to affected areas
of the brain.
Mild brain injury – concussion
Severe brain injury—Penetration Injury, Contusions, Diffuse Axonal Injury (ie shaken
baby syndrome)

31. Neuroplasticity:
The brain's ability to reorganize itself by forming new neural connections throughout life.
Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease
and to adjust their activities in response to new situations or to changes in their environment.
Brain reorganization takes place by mechanisms such as "axonal sprouting" in which undamaged
axons grow new nerve endings to reconnect neurons whose links were injured or severed.
Undamaged axons can also sprout nerve endings and connect with other undamaged nerve cells,
forming new neural pathways to accomplish a needed function.
For example, if one hemisphere of the brain is damaged, the intact hemisphere may take over
some of its functions.The brain compensates for damage in effect by reorganizing and forming
new connections between intact neurons. In order to reconnect, the neurons need to be stimulated
through activity. For neurons to form beneficial connections, they must be correctly stimulated.
Neuroplasticity is also called brain plasticity or brain malleability.