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July 26, 2010

Physical Therapy and Cognitive Impairment

One of the most challenging aspect of my clinical internship this semester is working with patients who are cognitively impaired. Different kinds of brain injuries, such as stroke, yield different challenges to communication. Aphasia is an acquired communication disorder that impairs a person's ability to process language, but does not affect intelligence.

One type of aphasia is called receptive aphasia which affects a patient's ability to understand what is being told to them, as though everyone and everything around them is suddenly in a foreign language. They can speak, but what they produce is called "word salad," a combination of words that do not make any sense. When a patient has expressive aphasia, they can understand most of what is being said to them, but they may not be able to talk at all. Verbal apraxia is a type of speech difficulty where a person knows what they want to say, but they have little or no control over the muscles needed to form words. It must be horribly frustrating for them, and that's just the communication aspect of cognitive impairment.

Inattention and motivation are other aspects of cognitive impairment that challenge the therapist. The frontal lobe of the brain, the big part found in humans, is in charge of executive function, motor planning, and, in part, personality. The closer you get to the center of the brain and the brain stem, the more basic the functions, such as breathing, basic emotions, and motivation which is linked to neurotransmitters and brain chemicals like dopamine and endorphins.

Lack of dopamine, implicated in Parkinson's disease, is causes slow movements, tremors, freezing, dementia, rigid muscles, loss of automatic movement, speech changes, and impaired balance and posture. It's important to know when working with Parkinson's patients that simple, one-word commands, usually helpful when working with cognitively impaired patients, can cause freezing.

I tend to take the polite tack when working with people. So I ask them, "Can you pick up your leg (or would you like to walk, or whatever)?" This usually elicits an "I can't" response from patients. So I've had to learn to get a little bossy. "Let's walk," I say, and, voila, they walk. If you ask someone to think about what is automatic, they may not be able to perform automatic movements that they've been doing all their life. Parkinson's patients require less staccato commands to prevent freezing episodes, such as, "Why don't we take a walk?" in order to tap into those automatic movements. This is not something I likely would have remembered in the classroom discussing theory, which is the purpose of clinical education.

Posted by linda at July 26, 2010 8:45 AM