INFLAMMATORY AND
INFECTIOUS DISORDERS OF
BRAIN
Dr. Purti P Haral
CLASSIFICATION
Based on anatomical location
 Brain abscess
 Meningitis
a) Bacterial
b) Viral or asceptic
 Encephalitis


The most common agents producing meningitis are
bacterial and encephalitis are viral
The site of infection determines signs and
symptoms of CNS whereas the infecting organisms
determine the time course and severity of the
problem.
BRAIN ABSCESS
Penetrating wound to the brain
 By extension of any local infection such as sinusitis or
otitis
 Hematogeous spread from a distant site of infection
Classic presenting triad
1. Fever
2. Increased ICP
3. Focal neurological deficit



Alteration of consciousness
Frontal, temporal or parietal lobe may be seen
MENINGITIS


It denotes an infection spread through the CSF with
the inflammatory process involving the pia and
arachnoid mater, the subarachnoid space and the
adjacent superficial tissues of brain and sp cord
Pachymeningitis- involvement of dura mater
BACTERIAL MENINGITIS



Acute bacterial-aerobic bacteria which may be gram
+ve or gram –ve
Neonatal or old adults- E coli (gram -ve)
Community acquired- H influenzae
N meningitidis
S pnumoniae
CLINICAL FEATURES




Convulsions seen in children
Nuchal rigidity(subarachnoid irritation)
Painful Cx flexn- as it stretches the inflamed
meninges,nerve roots and sp cord.
Pain-triggers a reflex spasm of neck extensors to
splint the area against further Cx flexion.
CLINICAL TESTS

Kernigs test

Brudzinski’s sign


These signs not seen when patient is in coma ,
decreased ms tone and absent reflexes
CSF culture- increased protein count
reduced glucose count
KERNIGS TEST



The maneuver is usually performed with the patient
supine with hips and knees in flexion.
Extension of the knees is attempted:
The inability to extend the patient’s knees beyond
135 degrees without causing pain constitutes a
positive test for Kernig’s sign.
BRUDZINSKI’S SIGN
With the patient supine, the physician places one
hand behind the patient’s head and places the
other hand on the patient’s chest.
 The physician then raises the patient’s head (with
the hand behind the head) while the hand on the
chest restrains the patient and prevents the
patient from rising.
 Flexion of the patient’s lower extremities (hips
and knees) constitutes a positive sign.
 Brudzinski’s neck sign has more sensitivity than
Kernig’s sign.

VIRAL MENINGITIS




Symptoms less severe
Irritable, lethargic, headaches.
Normal glucose levels
It does not produce any residual neurological
sequel and full recovery is anticipated within few
days to few weeks.
ENCEPHALITIS


It refers to a group of diseases characterised by
inflammation of the parenchyma of the brain and its
surrounding meninges.
Coma, cranial nerve palsy, hemiplegia, involuntary
movts or ataxia seen in extensive cerebral damage
MANAGEMENT- (GOALS)





Postural control is optimized as demonstrated by the
ability to maintain a position against gravity and
ability to automatically adjust before and
continuously during movt.
Selective , voluntary movt patterns within functional
activities are optimized
Performance of functional activities is enhanced
Integration of sensory information is fostered
Cognitive status and psychological responses are
optimized.
POSTURAL CONTROL
Optimal postural control is defined by 2 elements:
1.
The client should have the ability to maintain a vertical
orientation in regard to gravity and should be able to
maintain his balance in the presence of both internal and
external perturbations.
2.
Automatic adjustments should occur in anticipation
Both the elements should be performed with minimal
physical or cognitive effort of the client.
HORAC – 5 COMPONENTS FOR NORMAL
POSTURAL CONTROL
1.
2.
3.
4.
5.
Vertical orientation
Anticipatory postural control
Reactive postural control
Sensory organisation
Dynamic postural control for gait
VERTICALITY
Augment sensory feedback
1. Mirrors
2. Force plates
3. Flashlight attached to the client that shines on a
target when he is vertical
4. Manual skills such as positioning the client and
using approximation to reinforce the position
 Progression can be done by maintaining the
position and manipulate objects with his
extremites

CNS - ORGANISATION
It is organised around tasks and not movement
patterns
 Eg . Keeping a book balanced on his head while
sitting and standing
 Use of videotapes
 Stepping with eyes closed.

LIMITS OF STABILITY PERCEPTION PROBLEMS
1.
2.
3.
Computerised feedback of actual versus possible
Weight shifting exs with feedback
/targets(somatosensory/visual/both)
Surface orientation exs ( static ,ankle sway, hip
strategies)
ANTICIPATORY CONTROL PROBLEMS


It involves the postural preset which
positions the trunk to allow skilled use of the
extremities without loss of balance
It requires the client to recognise the
situation and the likely destabilizing force ,
so destabilizing will not occur.


The process requires memory and the ability
to recognise the critical environment and task
cues.
Interventions focus on practicing both the
postural adjustments and focal action before
the 2 components are combined
ANTICIPATORY CONTROL


1.
2.
Mental rehearsals(wt shift, then move)
Practice limb movts (start slow then fast)
Interact with environment with static BOS such as
reaching up in cupboard, opening a door, opening a
drawer, lifting a suitcase, lifting a bag of groceries
etc.
Interact with environment with a dynamic BOS such
as stepping up, kicking a ball,stepping over an
object, around an object, inclined surface
Practice the anticipatory postural adjustment
2. Practice the focal action while supported
3. Combine 1 and 2 while unsupported
4. Practice varying similar tasks(predictable to
unpredictable)
Eg- lifting objects with different weights, alternate it
and then varied pattern
1.
REACTIVE POSTURAL CONTROL PROBLEMS
Work to regain balance strategies (ankle, hip
and stepping)
 Begin with self perturbations and progress to
reacting to external perturbations
 Need to learn to match the magnitude and
direction of perturbation
 Physioballs, tilt boards, reach outs , weight
bearing

SENSORY INTEGRATION PROBLEMS
If overeliant on vision, help patient with
another strategy
 Surface orientation exs (somatosensory
feedback)
1. Textured surface
2. Textured surface + visual tracking
3. Textured surface with vision occluded


1.
2.
3.
4.
5.
6.
Enhancing use of vestibular system
Compliant surface with stationary visual target
Compliant surface + visual tracking
Compliant surface with moving visual
background
Changing surface + head turns
Changing surface + head turns + moving visual
background
Obstacle course with varying sensory demands
DYNAMIC BALANCE PROBLEMS IN GAIT
Alter the sensory contexts(eg. resisted walking)
 Walking and reading signs right and left
 Carrying objects and looking at items carried
 Walking with quik steps(predictable distances
and reactive)
 Practice falling without injury and getting up;
practice slips and trips
 Gesturing while walking


1.
2.
3.
4.
Walking and negotiating obstacles
(around and over)
Practice both around and over obstacles
Larger steps,standing on one foot,changing
directions
Practice stopping quickly with feet in target
Practice shorter steps on a slippery surface;
braiding




The patients ability to demonstrate optimal post
control may be restricted by the presence of
hypertonicity or hypotonicity.
High levels of muscle activity may be present in a
stereotypical ms distribution in the extremities
whereas the activity of the trunk musculature may be
too low to support an antigravity posture.
Vestibular input that is slow and rhythmical may
promote a generalized relaxation of skeletal ms
activity
In some patients, the trunk remains stiff in movt
sequences in which segmental response between the
upper and lower trunk should occur



Repetitions of rhythmical movts in sidelying where
therapist gently and progressively stretches the pelvis
in one direction around the body axis while moving
the shoulder girdle in the opposite direction and then
reverses the movt may effectively alter the
biomechanical and neurological contributions to the
stiffness
Vestibular input- labyrinths should be stimulated by
quick stops and starts with changes in direction
The program should include the introduction of
movts in all planes
SELECTIVE VOLUNTARY MOVT PATTERNS WITHIN
FUNCTIONAL ACTIVITIES ARE OPTIMIZED



Quality , selective ,voluntary movt patterns within
the framework of functional activities rather than
isolated and abstract movts
Performance of functional activities -perform both
mobility and stability patterns with the extremities
Mobility patterns-placing the extremities(eg. Swing
phase of gait or reaching for a doorknob)



Clients who exhibit stereotypical posturing of the
upper extremity require intervention to change the
initial position of the extremity before movts are
attempted.
Approximation – therapist manual contacts for the
application of the force are on the weight bearing
surfaces of the hand
If the flexed position of the wrist prohibits
application of the force to the heel of the palm, it can
be applied to the fist.



It is imp to reduce spasticity before passive movt is
attempted so that more appropriate position can be
assumed without inappropriately stretching the
spastic ms.
Selective movt is usually made through a massive
effort and overactivation of the ms groups .
Relearn selective activation of motor units rather
than mass firing patterns




Electrical stimulation can be used to elicit correct
movt pattern (FES)
It elicits correct movt so that the client could learn
from the feel of the correct pattern.
Adjust the practice schedule – with/ without
electrical stimulation---this avoids problem of
reliance on the device to produce the movt.
EMG biofeedback can be used to achieve activation of
specific ms groups and also to reduce the activity of
specific ms groups
Mobilty patterns in the upper extremity:
Freedom of the scapula to adjust appropriately to the
position of the humerus
 The mobility of scapula can be addressed through
techniques that result in a general decrease in ms
activity and diagonal movt patterns of scapula
 Scapular stabilizers- rhomboids, trapezius,serratus
anterior allow appropriate adjustment of the scapula
as well as providing the fixation base on which
humeral elevation can occur.

Performance of movt patterns should progress
to an ability to reverse the direction of the
movt.
 Incorporating reversal of movt patterns within
the intervention program prepares the client
to deal with situations involving unexpected
adjustments in the movt sequence.



Sensory cues to elicit movt patterns must be
consistent.
Once the pattern is well established the intervention
program can be designed to reduce the cues
progressing toward the ability of the patient to
perform the activity in response to the demands
of the situation rather than to externally imposed
cues
PERFORMANCE OF FUNCTIONAL ACTIVITIES IS
ENHANCED

The intervention strategy must focus on the quality of
the patients ability to assume a posture, maintain the
posture ,move within the posture(static and dynamic
equilibrium responses to both self generated and
external perturbations) and move out of posture.
INTEGRATION OF SENSORY INFORMATION IS
FOSTERED


The therapist must assess the patients ability to
respond to multisensory inputs i.e. cutaneous,
proprioceptive, auditory and visual input.
The ability to respond adaptively progresses from a
response to a single sensory system input to a
response to the input in the presence of multiple
system input and then to an adaptive response based
on inputs from 2 or more sources.
At the highest level, the patient will
demonstrate cross modal learning in which
input from one sensory system will evoke a
response based on input previously obtained
through a different system.
 Eg . Recognition of comb by touch is based on
the precept of “combness ” usually obtained
initially by visual input.
