Encephalitis: PT assessment and management

Encephalitis

Dr. L. Surbala (MPT Neurology)2

Introduction

Encephalitis is an acute inflammation of the parenchyma of brain & spinal cord

Encephalitis with meningitis is known as meningoencephalitis


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).


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


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


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


Encephalitis can follow or accompany common viral illnesses,

There are sometimes signs & symptoms of these illnesses beforehand

But often, encephalitis appears without warning.


Contagiousness

Brain inflammation itself is not contagious, Any viruses that cause encephalitis can be

infectious


Causes

Viral Other micro organisms


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).


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 age


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 systems


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


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 motionless

http://en.wikipedia.org/wiki/L-DOPA


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


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).

http://en.wikipedia.org/wiki/RNA

http://en.wikipedia.org/wiki/DNA


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.


Treatment

Maintain fluid & nourishment Sedatives Corticosteroids Antibiotics & antiviral Anticonvulsions


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 pattern


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)


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


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


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 function


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


Prevent chest complications

Breathing exercise, postural drainage & suctioning as required

Cervical & thoraxic mobility exercise Thoraxic expansion exercise Strengthening of respiratory muscles


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


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


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 casting


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


Normalize tone

Facilitatory & inhibitory techniques


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


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


Improve overall function

Maintenance of physical activity Maintenance of CV endurance Early Return to activity or work

Health & Medicine

Encephalitis: PT assessment and management