Amyotrophic Lateral Sclerosis (ALS)

Our primary focus is to slow the progression of the disease and help our clients preserve their independence and improve their quality of life.  Recent research is also beginning to confirm that exercise may be a key component in this endeavor. (ScienceDirect). Since each individual is uniquely affected, we customize your program based upon your functional abilities.

What is ALS?

Also known as "Lou Gehrig's Disease”, ALS is a non-traumatic, progressive, neurodegenerative motor neuron disease. As motor neurons, essential for body function, degenerate and eventually die, the ability of the brain to initiate and control muscle movement is lost. Over time this may cause total paralysis.

Symptoms

The initial symptoms of ALS can be quite varied in different people. One person may have trouble grasping a pen or lifting a coffee cup, while another person may experience a change in vocal pitch when speaking. ALS is typically a disease that involves a gradual onset.

The rate at which ALS progresses can be quite variable from one person to another. Although the mean survival time with ALS is three to five years, many people live five, 10 or more years. Symptoms can begin in the muscles that control speech and swallowing or in the hands, arms, legs or feet. Not all people with ALS experience the same symptoms or the same sequences or patterns of progression. However, progressive muscle weakness and paralysis are universally experienced.

Gradual onset, generally painless, progressive muscle weakness is the most common initial symptom in ALS. Other early symptoms vary but can include tripping, dropping things, abnormal fatigue of the arms and/or legs, slurred speech, muscle cramps and twitches, and/or uncontrollable periods of laughing or crying.

When the breathing muscles become affected, ultimately, people with the disease will need permanent ventilatory support to assist with breathing.

Since ALS attacks only motor neurons, the sense of sight, touch, hearing, taste and smell are not affected. For many people, muscles of the eyes and bladder are generally not affected.

Diagnosis

ALS is a difficult disease to diagnose. There is no one test or procedure to ultimately establish the diagnosis of ALS. It is through a clinical examination and series of diagnostic tests, often ruling out other diseases that mimic ALS, that a diagnosis can be established. A comprehensive diagnostic workup includes most, if not all, of the following procedures:

  • Electrodiagnostic tests including electomyography (EMG) and nerve conduction velocity (NCV)
  • Blood and urine studies including high resolution serum protein electrophoresis, thyroid and parathyroid hormone levels and 24-hour urine collection for heavy metals
  • Spinal tap
  • X-rays, including magnetic resonance imaging (MRI)
  • Myelogram of cervical spine
  • Muscle and/or nerve biopsy
  • A thorough neurological examination

* Information has been provided by the ALS Association http://www.alsa.org/


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Beau Morris
Traumatic Brain Injury

TBI is caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. These can range from slight to severe and have both temporary and lifelong effects to : attention, memory, motor function, coordination, balance, and more. 

What is Traumatic Brain Injury?

TBI is caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. These can range from slight to severe and have both temporary and lifelong effects to : attention, memory, motor function, coordination, balance, and more. 


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Beau Morris
Cerebral Palsy

Cerebral Palsy is one of the many neurological disorders that is treated at The Perfect Step. Although many people affected by cerebral palsy are able to walk, our goal at The Perfect Step is to improve on those abilities through gait training activities, strength training, and resistance exercises.  Our highly trained Specialists will focus on retrain the body to do things it cannot currently do.

What is Cerebral Palsy?

Initial signs of cerebral palsy are typically identified in infancy or early childhood but are permanent with no current cure. The disorder is presented in many different forms but affects muscle coordination and overall body movement due to abnormalities in the brain. Traditional treatment for individuals affected by cerebral palsy include physical therapy, speech therapy, medications to relieve pain, spasms, and seizures. Surgery may also be recommended for various problems related to loss of muscle control. Braces, orthotic devices, wheelchairs and other devices may be used to improved daily living and independence.

Causes

The cause of Cerebral Palsy is a brain injury or brain malformation that occurs while the brain is developing — before, during, or after birth. As a result of the brain damage during brain development a child’s muscle control, muscle coordination, muscle tone, reflex, posture and balance can be affected. It can also impact a child’s fine motor skills, gross motor skills, and oral motor functioning.

Every case of Cerebral Palsy is unique to the individual. This is due in part by the type of injury, extent of injury, and the timing of injury to the developing brain. The brain damage that causes Cerebral Palsy is a result of either:

  • Prenatal disturbance of brain cell migration – genetic and environmental factors disturb brain cell migration as cells move to their appropriate location during brain development.
  • Prenatal poor myelination (insulation) of developing nerve cell fibers – brain function is impeded when poor myelin provides an inadequate protective covering over nerve cells that aid in the transmission.
  • Perinatal brain cell death – events in the birthing process that rupture blood vessels or starve oxygen to the brain.
  • Postnatal non-functional or inappropriate connections (synapses) between brain cells – trauma, infections, and asphyxia that damage connections developed in the brain.

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Beau Morris
Multiple Sclerosis

It's never too late to start recovery. At The Perfect Step our goals for those suffering with multiple sclerosis are to slow down the progress of the disease, help increase recovery during remission phases, and improve our clients' quality of life. As each individual with MS may have different difficulties, we use a customized treatment program to help decrease long term fatigue and increase motor and cognitive function.

What is Multiple Sclerosis?

MS is a degenerative disease that affects the central nervous system. The immune system works against the central nervous system by attacking the myelin, the substance that protects and insulates the nerve fibers. Damaged myelin forms scar tissue limiting nerve impulses traveling to and from the spinal cord and brain- of which trigger a multitude of symptoms.

Symptoms

Some common symptoms are as follows

  • Fatigue
  • Walk (Gait) Difficulties
  • Numbness or Tingling
  • Spasticity
  • Weakness
  • Vision Problems
  • Dizziness and Vertigo
  • Bladder Problems
  • Sexual Problems
  • Bowel Problems
  • Pain
  • Cognitive Changes
  • Emotional Changes
  • Depression

Causes

While the cause (etiology) of MS is still not known, scientists believe that the interaction of several different factors may be involved. To answer this important question, studies are ongoing in the areas of immunology (the science of the body’s immune system), epidemiology (the study of patterns of disease in the population) and genetics. Scientists are also studying infectious agents that may play a role. Understanding what causes MS will speed the process of finding more effective ways to treat it and — ultimately — cure it, or even prevent it from occurring in the first place.

Immunologic Factors

In MS, an abnormal immune-mediated response attacks the myelin coating around nerve fibers in the central nervous system, as well as the nerve fibers themselves. In recent years, researchers have been able to identify which immune cells are mounting the attack, some of the factors that cause them to attack, and some of the sites (receptors) on the attacking cells that appear to be attracted to the myelin to begin the destructive process. Ongoing efforts to learn more about the immune-mediated process in MS — what sets it in motion, how it works, and how to slow or stop it — are bringing us closer to understanding the cause of MS.

Environmental Factors

MS is known to occur more frequently in areas that are farther from the equator. Epidemiologists — scientists who study disease patterns — are looking at variations in geography, demographics (age, gender and ethnic background), genetics, infectious causes and migration patterns in an effort to understand why.

Studies have shown that people born in an area with a high risk of MS who then move — or migrate — to an area with a lower risk before the age of 15 assume the risk of their new area. Such data suggest that exposure to some environmental agent before puberty may predispose a person to develop MS later on.

Growing evidence suggests that vitamin D plays an important role. People who live closer to the equator are exposed to greater amounts of sunlight year-round. As a result, they tend to have higher levels of naturally-produced vitamin D, which is thought to support immune function and may help protect against immune-mediated diseases like MS. The possible relationship between MS and sunlight exposure is currently being looked at in a Society-funded epidemiological study in Australia.

The evidence is also growing that smoking plays an important role in MS. Studies have shown that smoking increases a person’s risk of developing MS and is associated with more severe disease and more rapid disease progression. Fortunately, the evidence also suggests that stopping smoking — whether before or after the onset of MS — is associated with a slower progression of disability.

MS “clusters” — the perception that very high numbers of cases of MS have occurred in a specific time period or location — may provide clues to environmental or genetic risk for the disease. So far, cluster studies in MS have not produced clear evidence for the existence of any causative or triggering factor or factors in MS.

Infectious Factors

Since initial exposure to numerous viruses, bacteria and other microbes occurs during childhood, and since viruses are well-recognized as causes of demyelination and inflammation, it is possible that a virus or other infectious agent is the triggering factor in MS. More than a dozen viruses and bacteria — including measles, canine distemper, human herpes virus-6, Epstein-Barr, and Chlamydia pneumonia — have been or are being investigated to determine if they are involved in the development of MS, but none have been definitively proven to trigger MS.

Genetic Factors

While MS is not hereditary, having a first-degree relative such as a parent or sibling with MS does significantly increase an individual's risk of developing the disease. Studies have shown that there is a higher prevalence of certain genes in populations with higher rates of MS. Common genetic factors have also been found in some families where there is more than one person with MS. Some researchers theorize that MS develops because a person is born with a genetic predisposition to react to some environmental agent that, upon exposure, triggers an immune-mediated response. Sophisticated new techniques for identifying genes are helping to answer questions about the role of genes in the development of MS.


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Beau Morris
Parkinson's Disease

While some healthcare professionals might be prone to prescribing medications to reduce tremors and progressive onsets of Parkinson’s, The Perfect Step believes that “Exercise is Medicine.” While exercise is important for most anybody to live, it can be a pivotal component for individuals living with Parkinson’s in increasing or maintaining balance, mobility, and basic movements to daily living. Intense exercise-based therapy, which is facilitated at TPS, can help contribute to slower declines of quality of life, rather than those who choose to not participate in exercise or making the body move. While there is not a cure or an exact science to preventing Parkinson’s or the onset of the disease, TPS believes that through participation in their exercise program, that clients can not only have better quality of life, but they also might be able to reduce and/or regain control of their tremors, which inhibit them.

What is Parkinson's?

Parkinson's disease (PD) is a neurodegenerative disorder that affects predominately dopamine-producing (“dopaminergic”) neurons in a specific area of the brain called substantia nigra. Symptoms generally develop slowly over years. The progression of symptoms is often a bit different from one person to another due to the diversity of the disease. People with PD may experience:

  • Tremor, mainly at rest and described as pill rolling tremor in hands. Other forms of tremor are possible

  • Slowness of movements (bradykinesia)
  • Limb rigidity
  • Gait and balance problems

The cause remains largely unknown. Although there is no cure, treatment options vary and include medications and surgery. While Parkinson’s itself is not fatal, disease complications can be serious. The Centers for Disease Control and Prevention (CDC) rated complications from PD as the 14th cause of death in the United States.

The first step to living well with Parkinson’s disease is to understand the disease and the progression:

It is possible to have a good to great quality of life with PD. Working with your doctor and following recommended therapies are essential in successfully treating symptoms by using dopaminergic medications. People with PD need this medication because they have low levels or are missing dopamine in the brain, mainly due to impairment of neurons in the substantia nigra.

It is important to understand that people with PD first start experiencing symptoms later in the course of the disease because a significant amount of the substantia nigra neurons have already been lost or impaired. Lewy bodies (accumulation of abnormal alpha-synuclein) are found in substantia nigra neurons of PD patients.

Scientists are exploring ways to identify biomarkers for PD that can lead to earlier diagnosis and more tailored treatments to slow down the disease process. Currently, all therapies used for PD improve symptoms without slowing or halting the disease progression.

In addition to movement-related (“motor”) symptoms, Parkinson’s symptoms may be unrelated to movement (“non-motor”).People with PD are often more impacted by their non-motor symptoms than motor symptoms. Examples of non-motor symptoms include: apathy, depression, constipation, sleep behavior disorders, loss of sense of smell and cognitive impairment.

In idiopathic Parkinson’s disease, progression tends to be slow and variable. Doctors often use the Hoehn and Yahr scale to gauge the progression of the disease over the years. The scale was originally implemented in 1967 and it included stages zero to five, where zero is no signs of Parkinson’s and five is advanced PD. It was later changed to become the modified Hoehn and Yahr scale.

Causes & Statistics

Parkinson’s disease (PD) is an extremely diverse disorder. While no two people experience Parkinson’s the same way, there are some commonalities. Parkinson’s affects about one million people in the United States and ten million worldwide. The main finding in brains of people with PD is loss of dopaminergic neurons in the area of the brain known as the substantia nigra.

Symptoms

Parkinson’s disease (PD) symptoms may be related to movement (motor symptoms) or unrelated to movement (non-motor symptoms). Each person with Parkinson's will experience symptoms differently. For example, many people experience tremor as their primary symptom, while others may not have tremors, but may instead have problems with balance.

By definition, Parkinson’s is a progressive disease. Although some people with Parkinson’s only have symptoms on one side of the body for many years, eventually symptoms will also affect the other side. Symptoms on the other side of the body often do not become as severe as symptoms on the initial side.

Treatment

There is no standard treatment for Parkinson’s disease (PD). Treatment for each person with Parkinson's is based on his or her symptoms.

Treatments include medication and surgical therapy. Other treatments include lifestyle modifications, like getting more rest and exercise.

There are many medications available to treat the Parkinson’s symptoms, although none yet that reverse the effects of the disease. It is common for people with PD to take a variety of these medications — all at different doses and at different times of day — to manage symptoms.

While keeping track of medications can be a challenging task, understanding your medications and sticking to a schedule will provide the greatest benefit from the drugs and avoid unpleasant “off” periods due to missed doses.

Exercise

Exercise is an important part of healthy living for everyone. For people with Parkinson’s disease (PD), exercise is more than healthy — it is a vital component to maintaining balance, mobility and activities of daily living. Exercise and physical activity can improve many PD symptoms. These benefits are supported by research.

The Parkinson’s Outcomes Project shows that people with PD who start exercising earlier and a minimum of 2.5 hours a week, experience a slowed decline in quality of life compared to those who start later. Establishing early exercise habits is essential to overall disease management.


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Beau Morris
Spina Bifida

A team approach is beneficial to the individual who is suffering from Spina Bifida. Because these individuals are suffering since birth, there are many hoops and hurdles to be crossed in terms of how the body physically grows up and develops, as well as the mental outlook that these individuals have on their life. The Perfect Step aims to serve as the component of trainer and therapist during the lifelong recovery process of somebody who is suffering from spina bifida. It is pivotal for individuals who are suffering from Spina Bifida to keep their body moving.

Due to their nature of their slowly developing limbs and muscle structure, one of the best things that an individual suffering from Spina Bifida can do is move, stretch, lengthen muscles, articulate joints, and stay active. The body was intended to move and it can become very easy for an individual suffering from Spina Bifida who has a tough time moving around and living an independent lifestyle, to become sedentary by nature. TPS aims to get these individuals out of the wheelchair and get their body in a functioning state and strong enough to live an independent lifestyle that is removed from the chair as much as possible. TPS does this through intense exercise and through modalities that promote stretching of muscles, agility, movement, and overall strengthening of the body.

What is Spina Bifida?

Spina bifida is a birth defect that occurs when the spine and spinal cord don't form properly. Spina Bifida literally means “split spine.” It falls under the broader category of neural tube defects. The neural tube is the embryonic structure that eventually develops into the baby's brain and spinal cord and the tissues that enclose them.

Normally, the neural tube forms early in pregnancy, and it closes by the 28th day after conception. In babies with spina bifida, a portion of the neural tube fails to develop or close properly, causing defects in the spinal cord and in the bones of the spine.

Spina bifida can range from mild to severe, depending on the type of defect, size, location and complications. When early treatment for spina bifida is necessary, it's done surgically, although such treatment doesn't always completely resolve the problem.

What are the different types of Spina Bifida?

Occult Spinal Dysraphism (OSD)

Infants with this have a dimple in their lower back. Because most babies with dimples do not have OSD, a doctor has to check using special tools and tests to be sure. Other signs are red marks, hyperpigmented patches on the back, tufts of hair or small lumps. In OSD, the spinal cord may not grow the right way and can cause serious problems as a child grows up. Infants who might have OSD should be seen by a doctor, who will recommend tests.

Spina Bifida Occulta

It is often called “hidden Spina Bifida” because about 15 % of healthy people have it and do not know it. Spina Bifida Occulta usually does not cause harm, and has no visible signs. The spinal cord and nerves are usually fine. People find out they have it after having an X-ray of their back. It is considered an incidental finding because the X-Ray is normally done for other reasons. However, in a small group of people with SBO, pain and neurological symptoms may occur. Tethered cord can be an insidious complication that requires investigation by a neurosurgeon.

Meningocele

A meningocele causes part of the spinal cord to come through the spine like a sac that is pushed out. Nerve fluid is in the sac, and there is usually no nerve damage. Individuals with this condition may have minor disabilities.

Myelomeningocele (Meningomyelocele), also called Spina Bifida Cystica

This is the most severe form of Spina Bifida. It happens when parts of the spinal cord and nerves come through the open part of the spine. It causes nerve damage and other disabilities. 70 to 90% of children with this condition also have too much fluid on their brains. This happens because fluid that protects the brain and spinal cord is unable to drain like it should. The fluid builds up, causing pressure and swelling. Without treatment, a person’s head grows too big, and may have brain damage. Children who do not have Spina Bifida can also have this problem, so parents need to check with a doctor.

How is Spina Bifida Treated?

  • Occult Spinal Dysraphism (OSD) — A child with OSD should see a surgeon. Most experts think that surgery is needed early to keep nerves and the brain from becoming more damaged as the child grows.
  • Spina Bifida Occulta — This type of spina bifida usually does not need to be treated. 
  • Meningocele — A child with Meningocele usually has it treated with surgery, and more often than not, the child is not paralyzed. Most children with this condition grow up fine, but they should be checked by a doctor because they could have other serious problems, too.
  • Meningomyelocele — A child with Meningomyelocele usually is operated on within two to three days of birth. This prevents infections and helps save the spinal cord from more damage.

What can you do to prevent Spina Bifida?

Women who are old enough to have babies should take folic acid before and during the first three months of pregnancy. Because half of the pregnancies in the United States are unplanned, the Spina Bifida Association asks women to take a vitamin with 400 mcg (0.4 mg) of folic acid each day during the years of their lives when they are possibly able to have children.

Women who have a child or sibling with Spina Bifida, have had an affected pregnancy or have Spina Bifida themselves should take 4000 mcg (4.0 mg) of folic acid for one to three months before and during the first three months of pregnancy.

What is folic acid?

Folic acid is a vitamin that the body needs to grow and be healthy. It is found in many foods, but the man-made or synthetic form in pills is actually better absorbed by our bodies.

What conditions are associated with Spina Bifida?

  • Mobility – walking and getting around
  • Bladder, Bowel & gastrointestinal disorders
  • Latex allergy
  • Obesity
  • Skin breakdown
  • Learning disabilities
  • Social issues
  • Tendonitis
  • Sexual issues

What physical limitations exist?

People with Spina Bifida must learn how to get around on their own without help, by using things like crutches, braces or wheelchairs. With help, it also is possible for children to learn how to go to the bathroom on their own. Doctors, nurses, teachers and parents should know what a child can and cannot do so they can help the child (within the limits of safety and health) be independent, play with kids that are not disabled and to take care of him or herself.

Can children with Spina Bifida grow up and live full lives?

Yes. With help, children with Spina Bifida can lead full lives. Most do well in school, and many play in sports. Because of today’s medicine, about 90% of babies born with Spina Bifida now live to be adults, about 80% have normal intelligence and about 75% play sports and do other fun activities.

How is Spina Bifida managed?

As type and level of severity differ among people with Spina Bifida, each person with the condition faces different challenges and may require different treatments.

The best way to manage Spina Bifida is with a team approach. Members of the team may include neurosurgeons, urologists, orthopedists, physical and occupational therapists, orthotists, psychologists and medical social workers.


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Beau Morris
Spinal Cord Injury

Much like a fingerprint, no two injuries or clients are alike, so treatment can look different in each case.  Our approach is based in stimulating and reactivating the client’s nervous system for the purpose of reorganizing the brains pathways.  Our goal is guide each client though the phases of recovery - starting with reactivating the nervous system, introducing load bearing exercise, and practicing independent movements under the care of a Recovery Specialist.

What is a Spinal Cord Injury?

Spinal cord injury is an insult to the spinal cord resulting in a change in normal motor, sensory, or autonomic function. Many clients at The Perfect Step have suffered some type of spinal cord injury due to either traumatic events (such as automobile accidents, diving, or gun shot wounds) or due to inflammation caused by certain viral diseases (Lyme disease, West Nile virus, influenza, etc). The level of injury ranges from C2 to L2 with diagnoses of complete or incomplete. 

A spinal cord injury — damage to any part of the spinal cord or nerves at the end of the spinal canal (cauda equina) — often causes permanent changes in strength, sensation and other body functions below the site of the injury.

If you've recently experienced a spinal cord injury, it might seem like every aspect of your life has been affected. You might feel the effects of your injury mentally, emotionally and socially.

Many scientists are optimistic that advances in research will someday make the repair of spinal cord injuries possible. Research studies are ongoing around the world. In the meantime, treatments and rehabilitation allow many people with spinal cord injuries to lead productive, independent lives.

Symptoms

Your ability to control your limbs after a spinal cord injury depends on two factors: the place of the injury along your spinal cord and the severity of injury to the spinal cord.

The lowest normal part of your spinal cord is referred to as the neurological level of your injury. The severity of the injury is often called "the completeness" and is classified as either of the following:

  • Complete: If all feeling (sensory) and all ability to control movement (motor function) are lost below the spinal cord injury, your injury is called complete.
  • Incomplete: If you have some motor or sensory function below the affected area, your injury is called incomplete. There are varying degrees of incomplete injury.

Additionally, paralysis from a spinal cord injury may be referred to as:

  • Tetraplegia: Also known as quadriplegia, this means your arms, hands, trunk, legs and pelvic organs are all affected by your spinal cord injury.
  • Paraplegia: This paralysis affects all or part of the trunk, legs and pelvic organs.

Your health care team will perform a series of tests to determine the neurological level and completeness of your injury.

Spinal cord injuries of any kind may result in one or more of the following signs and symptoms:

  • Loss of movement
  • Loss or altered sensation, including the ability to feel heat, cold and touch
  • Loss of bowel or bladder control
  • Exaggerated reflex activities or spasms
  • Changes in sexual function, sexual sensitivity and fertility
  • Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cord
  • Difficulty breathing, coughing or clearing secretions from your lungs

Emergency signs and symptoms

Emergency signs and symptoms of a spinal cord injury after an accident may include:

  • Extreme back pain or pressure in your neck, head or back
  • Weakness, incoordination or paralysis in any part of your body
  • Numbness, tingling or loss of sensation in your hands, fingers, feet or toes
  • Loss of bladder or bowel control
  • Difficulty with balance and walking
  • Impaired breathing after injury
  • An oddly positioned or twisted neck or back

Diagnosis

In the emergency room, a doctor may be able to rule out a spinal cord injury by careful inspection and examination, testing for sensory function and movement, and by asking some questions about the accident.

But if the injured person complains of neck pain, isn't fully awake, or has obvious signs of weakness or neurological injury, emergency diagnostic tests may be needed.

These tests may include:

  • X-rays: Medical personnel typically order these tests on people who are suspected of having a spinal cord injury after trauma. X-rays can reveal vertebral (spinal column) problems, tumors, fractures or degenerative changes in the spine.
  • Computerized tomography (CT) scan: A CT scan may provide a better look at abnormalities seen on an X-ray. This scan uses computers to form a series of cross-sectional images that can define bone, disk and other problems.
  • Magnetic resonance imaging (MRI): MRI uses a strong magnetic field and radio waves to produce computer-generated images. This test is very helpful for looking at the spinal cord and identifying herniated disks, blood clots or other masses that may be compressing the spinal cord.

A few days after injury, when some of the swelling may have subsided, your doctor will conduct a more comprehensive neurological exam to determine the level and completeness of your injury. This involves testing your muscle strength and your ability to sense light touch and pinprick sensations.

Treatment

Unfortunately, there's no way to reverse damage to the spinal cord. But researchers are continually working on new treatments, including prostheses and medications that may promote nerve cell regeneration or improve the function of the nerves that remain after a spinal cord injury.

In the meantime, spinal cord injury treatment focuses on preventing further injury and empowering people with a spinal cord injury to return to an active and productive life.


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Beau Morris
Stroke

It's never too late to start recovery. We’ll do an assessment and evaluation by one of our Certified Recovery Specialists and determine what functions have been compromised.  Our primary focus is to enable stroke clients to regain as much function as possible; whether it's optimizing balance and equilibrium or focusing on affected areas of the body.

What is a stroke?

A stroke, also known as a cerebrovascular accident (CVA), is damage to the brain tissue due to a disruption in the blood supply to the brain. This disruption may be caused by ischemia or hemorrhage. An average of 700,000 Americans are affected by a stroke each year. The majority of these individual survive but with various complications.


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Beau Morris
Transverse Myelitis

The Perfect Step’s approach towards neurological ailments and neurological recovery is rooted in intense exercise, load bearing activities, and modalities that promote range of motion, muscle strengthening, and Patterned Neural Activity Recruitment to retrain the brain on how to connect to certain parts of the body. Transverse Myelitis in many ways can present itself much like the body of somebody who is suffering from spinal cord injury. Spinal cord injury is the cornerstone of the original methodology and process by which TPS originally treated clients. This approach towards recovery is rooted in prominent loadbearing and range of motion exercises that would alleviate soft-tissue contractures from those who are suffering from Transverse Myelitis.

TPS would use a approach towards therapy that would promote exercise and for the body to continue to move in a fashion where a person who is suffering from Transverse Myelitis might be able to subsequently avoid having to get splints for their ankles or other joints of the body. Intense exercise would also help contribute to other detrimental factors of individuals suffering from transverse myelitis: bowel and bladder function, skin integrity, pain, and spasticity. Because TPS takes an approach towards recovery that is rooted in exercise, the body thus reduces spasticity in pain because of movement, regains muscle mass which creates for better skin integrity, and increase blood flow and circulation allows for a possible chance of better bowel and bladder function.

What is Transverse Myelitis?

Transverse myelitis (TM) is a rare inflammatory disease causing injury to the spinal cord with varying degrees of weakness, sensory alterations, and autonomic dysfunction (the part of the nervous system that controls involuntary activity, such as the heart, breathing, the digestive system, and reflexes).  The first cases of acute myelitis were described in 1882 and were attributed to vascular lesions and acute inflammatory events. In England between 1922 and 1923 more than 200 post-vaccinial cases were noted as complications of the smallpox and rabies vaccines. Later reports revealed that TM was post-infectious in nature, and agents including measles, rubella and mycoplasma were directly isolated from patient’s spinal fluid. The term “acute transverse myelitis” was first used by an English neurologist in 1948 to describe a case of rapidly progressive paraparesis with a thoracic sensory level, occurring as a postinfectious complication of pneumonia. The Transverse Myelitis Consortium Working Group delineated diagnostic criteria for disease-associated TM and idiopathic TM along with a framework to differentiate TM from non-inflammatory myelopathies in 2002.

Epidemiology

TM has a conservatively estimated incidence of between 1 and 8 new cases per million per year, or approximately 1400 new cases each year in the US. Although this disease affects people of all ages, with a range of six months to 88 years, there are bimodal peaks between the ages of 10 to 19 years and 30 to 39 years.  In addition, approximately 25% of cases are in children. There is no gender or familial association with TM.  In 75-90% of cases TM is monophasic, yet a small percentage experience recurrent disease especially if there is a predisposing underlying illness.

Signs & Symptoms

The spinal cord carries motor nerve fibers to the limbs and trunk and sensory fibers from the body back to the brain. Inflammation within the spinal cord interrupts these pathways and causes the common presenting symptoms. TM generally presents with rapidly progressing muscle weakness or paralysis, beginning with the legs and potentially moving to the arms with varying degrees of severity. The arms are involved in a minority of cases and this is dependent upon the level of spinal cord involvement. Sensation is diminished below the level of spinal cord involvement in the majority of individuals. Pain (ascertained as appreciation of pinprick by the neurologist) and temperature sensation are generally diminished and appreciation of vibration (as caused by a tuning fork) and joint position sense may also be decreased. Many report a tight banding or girdle-like sensation around the trunk and that area may be very sensitive to touch.

In most cases a sensory level is documented, most commonly in the mid-thoracic region in adults or the cervical region in children. Pain in the back, extremities, or abdomen is also common while paresthesias (e.g., tingling, numbness, burning sensations) are typical in adults. Sexual dysfunction is also the result of sensory and autonomic involvement. Increased urinary urgency, bowel or bladder incontinence, difficulty or inability to void, and incomplete evacuation of bowel or constipation are other characteristic autonomic symptoms. Spasticity and fatigue are other symptoms common to transverse myelitis. Additionally, depression is often documented in TM patients and must be treated to prevent devastating consequences.

In some cases, symptoms progress over hours whereas in other instances, the presentation is over days. Neurologic function tends to decline during the 4-21 day acute phase, while 80% of cases reach their maximal deficit within 10 days of symptom onset. At its worst point, 50% of individuals have lost all movements of their legs, 80-94% experience numbness, paresthesias or banding or girdling, and almost all have some degree of bladder dysfunction.

Diagnosis

Diagnosis of TM is based on clinical and radiological findings. Clinical characteristics of myelopathy are bilateral signs and/or symptoms of sensory, motor or autonomic dysfunction attributable to the spinal cord or a clearly defined sensory level. Evidence of inflammation either on MRI as gadolinium enhancement or on lumbar puncture as elevated white blood cells or IgG index is frequently observed.

If a myelopathy is suspected based on history and physical examination, a gadolinium-enhanced magnetic resonance imaging (MRI) of the spinal cord is first obtained to assess if there is a compressive or inflammatory (gadolinium enhancing) lesion as signs and symptoms may be alike. It is essential to rule out compressive myelopathy (compression of the spinal cord), which can be caused by a tumor, herniated disc, stenosis (a narrowed canal for the cord), hematoma or abscess. Identifying these disorders is critical since immobilization to prevent further injury and early surgery to remove the compression may sometimes reverse neurologic injury to the spinal cord.

Lumbar puncture is used to look for surrogate markers for inflammation in the cerebrospinal fluid (CSF). These include elevated white cell counts, elevated protein and an elevated IgG index. It should be noted, however, that a significant percentage of individuals with a clinical pattern that otherwise resembles TM do not meet these inflammatory features and, therefore, the absence of inflammatory markers does not rule out TM.

To identify the underlying cause of the inflammatory process, further tests are recommended to assess for the presence of a systemic inflammatory disease – such as Sjögren’s syndrome, Lupus (SLE) and neurosarcoidosis. It is important to test for HIV infection, syphilis, vitamin B12 and copper levels to rule out possible causes of myelopathy.

A MRI of the brain is performed to screen for lesions suggestive of MS. If none of these tests are suggestive of a specific cause, the diagnosis is idiopathic transverse myelitis or parainfectious transverse myelitis (if there are other symptoms to suggest an infection).

In the absence of a systemic inflammatory disease, the regional distribution of demyelination within the CNS should be defined since several disorders (i.e. MS, NMOSD, or ADEM) may present with TM as the initial manifestation of a multiphasic disease. NMOSD involves primarily, but not exclusively, the optic nerve and the spinal cord. A gadolinium-enhanced brain MRI and visual evoked potential should be obtained to look for these entities. The absence of multifocal areas of demyelination would suggest a diagnosis of isolated TM and lead to appropriate treatment measures.

Non-inflammatory myelopathies include those caused by arterial or venous ischemia (blockage), vascular malformations, radiation, fibrocartilaginous embolism or nutritional/metabolic causes and appropriate work ups under these situations might include aortic ultrasound, spinal angiogram or evaluation of pro-thrombotic risk factors.

Sub-Types of Myelitis (Longitudinally Extensive and Partial Myelitis)

Within the category of idiopathic TM, it may be of further value to distinguish between acute partial TM, acute complete TM and longitudinally extensive TM (LETM), since these syndromes present distinct differential diagnoses and prognoses.

Acute partial transverse myelitis refers to mild or grossly asymmetrical spinal cord dysfunction with an MRI lesion of less than 3 vertebral segments. Acute complete TM refers to complete or near complete clinical deficits below the lesion and an MRI lesion of less than 3 vertebral segments. LETM has a complete or incomplete clinical picture but an MRI lesion that is longer than or equal to 3 vertebral segments. By definition, a brain MRI is considered to be negative in this population. There is a lesser likelihood of presenting with oligoclonal bands (abnormal antibodies), or relapse with a second bout of myelitis, and a very low transition rate to MS (likely < 5 percent).

Potential Causes

The possible causes of transverse myelitis can be quite varied. Transverse myelitis may occur in isolation or in the setting of another illness. Idiopathic transverse myelitis is assumed to be a result of abnormal and excessive activation of an immune response against the spinal cord that results in inflammation and tissue damage.

TM often develops in the setting of viral and bacterial infections, especially those which may be associated with a rash (e.g., rubeola, varicella, variola, rubella, influenza, and mumps). The term parainfectious suggests that the neurologic injury associated with TM may be related to direct microbial infection and injury as a result of the infection, direct microbial infection with immune-mediated damage against the agent, or remote infection followed by a systemic response that induces neural injury. Approximately one third of individuals with TM report a febrile illness (flu-like illness with fever) in close temporal relationship to the onset of neurologic symptoms. In some cases, there is evidence that there is a direct invasion and injury to the cord by the infectious agent itself (especially poliomyelitis, herpes zoster, AIDS and Lyme neuroborreliosis). However, causality has not been established. A bacterial abscess can also develop around the spinal cord and injure the cord through compression, bacterial invasion and inflammation.

Experts believe that in many cases infection causes a derangement of the immune system, which leads to an indirect autoimmune attack on the spinal cord, rather than a direct attack by the organism. One theory to explain this abnormal activation of the immune system toward human tissue is termed molecular mimicry. This theory postulates that an infectious agent may share a molecule that resembles or mimics a molecule in the spinal cord. When the body mounts an immune response to the invading virus or bacterium, it also responds to the spinal cord molecule with which it shares structural characteristics. This leads to inflammation and injury within the spinal cord.

Although a causal relationship has not been established, TM has been anecdotally reported following influenza and booster Hepatitis B vaccinations. One theory suggests that it is possible that the vaccination may have excited an autoimmune process. It is critically important to bear in mind that extensive research has demonstrated that vaccinations are safe, and the potential link to TM may only be coincidental or at worst an exceptionally rare complication.

As mentioned above, TM may be a relatively uncommon manifestation of several autoimmune diseases, including systemic lupus erythematosus (SLE), Sjogren’s syndrome, and sarcoidosis. SLE is an autoimmune disease of unknown cause that affects multiple organs and tissues in the body. Sjogren’s disease is another autoimmune disease characterized by invasion and infiltration of the tear and salivary glands by white blood cells with resultant decreased production of these fluids leading to dry mouth and dry eyes. Several tests can support this diagnosis: the presence of a SS-A antibody in the blood, ophthalmologic tests that confirm decreased tear production and the demonstration of lymphocytic infiltration in biopsy specimens of the small salivary glands (a minimally invasive procedure). Neurologic manifestations are unusual in Sjogren’s syndrome, but spinal cord inflammation (transverse myelitis) can occur. Sarcoidosis is a multisystem inflammatory disorder of unknown cause and manifested by enlarged lymph nodes, lung inflammation, various skin lesions, liver and other organ involvement. In the nervous system, various nerves, as well as the spinal cord, may be involved. Diagnosis is generally confirmed by biopsy, demonstrating features of inflammation typical of sarcoidosis.

Myelitis related to cancer (called a paraneoplastic syndrome) is uncommon. There are several reports in the medical literature of a severe myelitis occurring in association with a malignancy. In addition, there are a growing number of reports of cases of myelopathy associated with cancer in which the immune system produces an antibody to fight off the cancer and this cross-reacts with the molecules in the spinal cord neurons. It should be emphasized that this is an unusual cause of myelitis.

Vascular causes are noted because they present with the same problems as transverse myelitis. However, this is really a distinct problem primarily due to inadequate blood flow to the spinal cord instead of actual inflammation. The blood vessels to the spinal cord can close up with blood clots or atherosclerosis or burst and bleed. This is essentially a “stroke” of the spinal cord.

Acute Treatments

Intravenous Steroids

Intravenous steroid treatment is the first line of therapy often used in acute TM. Corticosteroids have multiple mechanisms of action including anti-inflammatory activity, immunosuppressive properties, and antiproliferative actions. Though there is no randomized double-blind placebo-controlled study that supports this approach, evidence from related disorders and clinical experience support this treatment. At the Johns Hopkins TM Center, the standard of care includes intravenous methylprednisolone (1000 mg) or dexamethasone (200 mg) for 3 to 5 days unless there are compelling reasons to avoid this therapy. The decision to offer continued steroids or to add a new treatment is often based on the clinical course and MRI appearance at the end of 5 days of steroids.

Plasma Exchange (PLEX)

PLEX is often initiated in moderate to severe TM (i.e., inability to walk, markedly impaired autonomic function, and sensory loss in the lower extremities) in individuals who show little clinical improvement after instituting 5 to 7 days of intravenous steroids, but may also be initiated at first presentation. PLEX is believed to work in autoimmune CNS diseases through the removal of specific or nonspecific soluble factors likely to mediate, be responsible for, or contribute to inflammatory-mediated target organ damage. PLEX has been shown to be effective in adults with TM and other inflammatory disorders of the CNS.

Other Immunomodulatory Treatment

If there is continued progression despite intravenous steroid therapy and PLEX, pulse dose intravenous cyclophosphamide (800–1000 mg/m2) is considered. Cyclophosphamide is known to have immunosuppressive properties. From the Johns Hopkins TM Center experience, it has been reported that PLEX provided an added benefit to steroids in patients who were not at a disability level of ASIA A and who did not have a history of autoimmune disease. For those who were classified at a disability level of ASIA A at their nadir, they showed a significant benefit when given combination therapy with steroids, PLEX and IV cyclophosphamide. Cyclophosphamide should be administered under the supervision of an experienced oncology team, and caregivers should monitor the patient carefully for hemorrhagic cystitis and cytopenias.

Chronic immunomodulatory therapy should be considered for recurrent TM. The ideal treatment regimen is not known and it is important for your neurologist to consult with a specialist who has significant experience in treating these rare, recurrent neuroimmunologic disorders.

Prognosis & Management

Recovery from TM may be absent, partial or complete and generally begins within 1 to 3 months after acute treatment. Historic data, not controlling for treatment, suggested that approximately 1/3 of individuals recover with little or only minor symptoms, 1/3 are left with a moderate degree of permanent disability and 1/3 have virtually no recovery and are left severely functionally disabled. These data, however, predate a number of more aggressive treatment protocols and are likely inaccurate. In present day experiences the outcomes seem to be better than this distribution. Most show good to fair recovery. Some studies have shown that the rapid progression of clinical symptoms, the presence of back pain, and the presence of spinal shock, as well as para-clinical evidence, such as absent central conduction on evoked potential testing and the presence of 14-3-3 protein in the cerebrospinal fluid (CSF) during the acute phase are often indicators of a less complete recovery. These markers are imperfect and do not assume aggressive rehabilitation or treatment strategies.

TM can be the presenting feature of Multiple Sclerosis. In individuals with acute partial transverse myelitis and normal brain MRI, about 10-33 percent develop MS over a five to ten-year period. If the brain MRI shows lesions, the transition rate to clinically definite MS is known to be quite high, in the range of 80 to 90 percent within a few years. Those who are ultimately diagnosed with MS are more likely to have asymmetric clinical findings, predominant sensory symptoms with relative sparing of motor systems, MR lesions extending over fewer than 2 spinal segments, abnormal brain MRI, and oligoclonal bands in the CSF.

Although typically a monophasic disease, in a subset of cases that manifest a history of systemic autoimmune disease, TM can be recurrent. Recurrence can often be predicted at the initial acute onset based on multifocal lesions in the spinal cord, lesions in the brain, presence of anti-Rho antibody, underlying mixed connective tissue disease, the presence of oligoclonal bands in the cerebrospinal fluid, and/or NMO-IgG antibodies.

Long-Term Care

After the acute phase, rehabilitative care to improve functional skills and prevent secondary complications of immobility involves both psychological and physical accommodations. There is very little written in the medical literature specifically dealing with rehabilitation after transverse myelitis. However, much has been written regarding recovery from spinal cord injury (SCI), in general, and this literature applies. The physical issues include bowel and bladder management, sexuality, maintenance of skin integrity, spasticity, activities of daily living (i.e., dressing), mobility, and pain.

It is important to begin occupational and physical therapies early during the course of recovery to prevent the inactivity related problems of skin breakdown and soft tissue contractures that lead to a decreased range of motion. Assessment and fitting for splints designed to passively maintain an optimal position for limbs that cannot be actively moved is an important part of the management at this stage.

The long-term management of TM requires attention to a number of issues. These are the residual effects of any spinal cord injury, including TM. In addition to chronic medical problems, there are the ongoing issues of ordering the appropriate equipment, reentry into school, re-socialization into the community, and coping with the psychological effects of this condition by the patients and their families. During the early recovery period, family education is essential to develop a strategic plan for dealing with the challenges to independence following return to the community.

Bladder Function

Bladder function is almost always at least transiently impaired in patients with TM. Immediately after the onset of TM, there is frequently a period of transient loss or depression of neural activity below the involved spinal cord lesion, referred to as “spinal shock,” which lasts about 3 weeks. Following this period, two general problems can affect the bladder. The bladder can become overly sensitive, and empty after only a small amount of urine has collected, or relatively insensitive, causing the bladder to become over extended and overflow. An overly distended bladder increases the likelihood of urinary tract infections and, in time, may threaten the health of the kidneys. Depending on the dysfunction, treatment options include timed voiding, medicines, external catheters for males (a catheter connected to a condom), padding for women, intermittent internal self-catheterization, an indwelling catheter or electrical stimulation. Surgical options may be appropriate for some people.

Bowel Function

Another major area of concern is effective management of bowel function. A common problem in spinal cord injury is difficulty with evacuation of stool, although fecal incontinence can also occur. The neurologic pathways for defecation are similar to those of the bladder. Many lacking voluntary control of the bowel may still be able to achieve continence by diet, strategic use of stool softeners and fiber, and the technique of rectal stimulation. Other aids include suppositories and oral medications. A high-fiber diet, adequate and timely fluid intake, and medications to regulate bowel evacuations are the basic components of success. Regular evaluations by medical specialists for adjustment of the bowel program are recommended to prevent potentially serious complications. There are some surgical options, although this is rarely necessary.

Sexual Dysfunction

Sexual dysfunction involves similar innervation and analogous syndromes as those found in bladder dysfunction. Treatment of sexual dysfunction should take into account baseline function before the onset of TM. Of the utmost importance is adequate education and counseling about the known physical and neurologic changes that TM has on sexual functioning. Because of the similarities in innervation between sexual and bladder function, patients with sexual dysfunction should be encouraged to empty their bladders before sexual stimulation to prevent inopportune incontinence. The mainstays of treatment of erectile dysfunction in men are inhibitors of cGMP phosphodiesterase, type 5, which will allow most of men with TM to achieve adequate erections for success in intercourse through a combination of reflex and/or psychogenic mechanisms. Although less effective in women, these same types of medications have been shown capable of enhancing a woman’s sexual functioning. The most commonly used oral erectile dysfunction drugs are Viagra (sildenafil), Levitra (vardenafil), and Cialis (tadalafil). Although sexual experience is impacted by spinal cord injury, sensual experience and even orgasm are still possible. Lubricants and aids to erection and ejaculation (for fertility) are available. Adjustment to altered sexuality is aided by an attitude of permissive experimentation, as the previous methods and habits may no longer serve.

Skin Breakdown

Skin breakdown occurs if the skin is exposed to pressure for a significant amount of time, without sensation or the strength shift position as necessary. Sitting position should be changed at least every 15 minutes. This can be accomplished by standing, by lifting the body up while pushing down on armrests, or by just leaning and weight shifting. Wheelchairs can be supplied with either power mechanisms of recline or tilt-in-space to redistribute weight bearing. A variety of wheelchair cushions are available to minimize sitting pressure. Redness that does not blanch when finger pressure is applied may signal the beginning of a pressure ulcer. Good nutrition, vitamin C, and avoidance of moisture all contribute to healthy skin. Pressure ulcers are much easier to prevent than to heal.

Spasticity

Spasticity is often a very difficult problem to manage. The goal is to maintain flexibility with a stretching routine using exercises for active stretching and a bracing program with splints for a prolonged stretch. These splints are commonly used at the ankles, wrists, or elbows. Also recommended are appropriate strengthening programs for the weaker of the spastic muscles acting on a joint and an aerobic conditioning regimen. These interventions are supported by adjunctive measures that include antispasticity drugs (e.g., diazepam, baclofen, dantrolene, tizanidine), therapeutic botulinum toxin injections, and serial casting. The therapeutic goal is to improve the function of the individual in performing specific activities of daily living (i.e., feeding, dressing, bathing, hygiene, mobility) by improving the available joint range of motion, teaching effective compensatory strategies, and relieving pain.

Individuals with TM may find ordinary tasks such as dressing, bathing, grooming, and eating very difficult. Many of these obstacles can be mastered with training and specialized equipment. For example, long handled sponges can make bathing easier as can grab bars, portable bath seats and hand-held shower heads. For dressing, elastic shoe-laces can eliminate the need to tie shoes while other devices can aid in donning socks. Occupational therapists are specialists in assessing equipment needs and helping people with limited function perform activities of daily living. A home assessment by an experienced professional is often helpful.

Physical therapists assist with mobility. Besides teaching people to walk and transfer more easily, they can recommend mobility aids. This includes everything from canes (single point vs. small quad cane vs. large quad cane) to walkers (static vs. rolling vs. rollator) and braces. For a custom-fabricated orthotic (brace), an orthotist is necessary. Careful thought should go into deciding whether the brace should be an ankle-foot orthosis, whether it should be flexible or stiff, and what angle the foot portion should be in relationship to the calf portion. Some will benefit by a knee-ankle foot orthosis. Each person should be evaluated individually. The best results occur when a physician coordinates the team so that the therapists and orthotists are united on what is to be achieved. The physician best trained to take this role is the physiatrist.

Pain

Pain is common following transverse myelitis. The first step in treating pain effectively is obtaining an accurate diagnosis. Unfortunately, this can be very difficult. Causes of pain include muscle strain from using the body in an unaccustomed manner, nerve compression (i.e., compression of the ulnar nerve at the elbow due to excessive pressure from resting the elbow on an armrest continuously) or dysfunction of the spinal cord from the damage caused by the inflammatory attack. Muscle pain might be treated with analgesics, such as acetaminophen (Tylenol), non-steroidal, anti-inflammatory drugs such as naproxen or ibuprofen (Naprosyn, Alleve, Motrin), or modalities such as heat or cold. Nerve compression might be treated with repositioning and padding (i.e., an elbow pad for an ulnar nerve compression).

Nerve pain can be a significant challenge to find effective treatment. Nerve messages traveling through the damaged portion of the spinal cord may become scrambled and misinterpreted by the brain as pain. Besides the treatments listed above, certain antidepressants such as amitriptyline (Elavil), or anticonvulsants, such as carbamazepine, phenytoin, or gabapentin (Tegretol, Dilantin, Neurontin) may be helpful. Stress and depression should also be addressed since these conditions make pain harder to tolerate.

Depression

Individuals with TM should be educated about the effect of TM on mood regulation and routinely screened for the development of symptoms consistent with clinical depression. Warning signs that should prompt a complete evaluation for depression include failure to progress with rehabilitation and self-care, worsening fixed low mood, pervasive decreased interest, and/or social and professional withdrawal. A preoccupation with death or suicidal thoughts constitutes a true psychiatric emergency and should lead to prompt evaluation and treatment. Depression in TM is similar to the other neurologic symptoms patients endure, which are mediated by the effects of the immune system on the brain. Depression is remarkably prevalent in TM, occurring in up to 25% of those diagnosed at any given time, and is largely independent of the patient’s degree of physical disability. Depression is not due to personal weakness or the inability to “cope.” It can have devastating consequences; not only can depression worsen physical disability (such as fatigue, pain, and decreased concentration) but it can have lethal consequences. Suicide is the leading cause of death in TM. Despite the severity of the clinical presentation of depression in TM, there is a very robust response to combined aggressive psychopharmacologic and psychotherapeutic interventions. With appropriate recognition and treatment of TM depression, complete symptom remission is standard.


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