5.5 Neurological Conditions of the Central & Peripheral Nervous System
Key Takeaways
Spinal cord injury at or above T6 can trigger autonomic dysreflexia: sudden severe hypertension, pounding headache, and flushing above the lesion, managed by sitting the client upright, removing the trigger, and calling 911 if it does not resolve.
Multiple sclerosis symptoms often worsen temporarily with heat (Uhthoff's phenomenon), so full-body heat is avoided and sessions are paced around fatigue.
Parkinson's disease presents with resting tremor, rigidity, bradykinesia, and postural instability; orthostatic hypotension and falls are the main treatment-room risks.
ALS combines upper and lower motor neuron signs with preserved sensation, whereas Guillain-Barré syndrome is an acute ascending flaccid weakness that can compromise breathing and needs urgent medical care.
A seizure lasting more than 5 minutes, a first seizure, injury, or breathing difficulty afterward requires 911; never restrain the person or put anything in their mouth.
Neurological Conditions of the Central & Peripheral Nervous System
1. Why Neurological Conditions Matter on the CKT
The PCs-PIs appendix lists conditions of the central nervous system (CNS), conditions of the peripheral nervous system (PNS), and general neurological conditions among the commonly occurring conditions an entry-level RMT must be able to assess and treat safely (competencies 2.c and 3.1.c). The Guidelines for Foundational Knowledge (GFK) add a neuropathology list that includes stroke, cerebral palsy, Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis, demyelinating diseases, spinal cord injury, and post-polio syndrome. Exam questions usually test three things: recognizing the condition from its signs, knowing the emergency that can occur in the treatment room, and choosing a safe modification.
Before treatment, the therapist confirms the medical diagnosis, current medications, recent changes, sensation, skin integrity, communication ability, and the client's capacity to consent. When a client lacks capacity, consent comes from a substitute decision-maker, as described in Chapter 11.
2. Upper vs. Lower Motor Neuron Patterns (Quick Review)
| Finding | Upper motor neuron (brain, spinal cord) | Lower motor neuron (anterior horn, root, nerve) |
|---|---|---|
| Tone | Spasticity (velocity-dependent) or rigidity | Flaccidity |
| Reflexes | Hyperreflexia, clonus, Babinski sign | Hyporeflexia or areflexia |
| Atrophy | Mild, from disuse | Marked, neurogenic |
| Fasciculations | Absent | Often present |
| Typical examples | Stroke, spinal cord injury, MS, cerebral palsy | Peripheral neuropathy, Guillain-Barré, post-polio |
ALS is the classic condition that shows both patterns at the same time.
3. Cerebrovascular Accident (Stroke)
- Pathophysiology: About 85% of strokes are ischemic (thrombotic or embolic occlusion) and the rest are hemorrhagic. A transient ischemic attack (TIA) produces stroke symptoms that resolve, but it is a warning sign that still needs emergency assessment.
- Recognition: Use FAST—Face drooping, Arm weakness, Speech difficulty, Time to call 911.
- Chronic presentation: Contralateral hemiparesis or hemiplegia with an early flaccid stage followed by spasticity; flexor synergy in the arm and extensor synergy in the leg; sensory loss; aphasia (expressive or receptive); unilateral neglect; and frequent hemiplegic shoulder pain with inferior subluxation.
- Treatment modifications: Test sensation before pressure or hydrotherapy; support the affected arm and never pull on it during positioning or transfers; use slow, rhythmic techniques that do not provoke spasticity; position the affected limbs in neutral with pillows; allow extra time and simple yes/no questions for clients with aphasia; and check that consent is understood.
4. Spinal Cord Injury (SCI)
- Classification: Tetraplegia (cervical lesion) or paraplegia (thoracic, lumbar, or sacral lesion), complete or incomplete.
- Common issues: Absent or reduced sensation below the lesion, spasticity, pressure injuries over bony prominences, orthostatic hypotension, impaired temperature regulation, neurogenic bladder and bowel, osteoporosis below the lesion, and heterotopic ossification around large joints.
- Autonomic dysreflexia: In injuries at or above T6, a noxious stimulus below the lesion (full bladder, kinked catheter, constipation, tight clothing or straps, a pressure area, ingrown toenail) triggers uncontrolled sympathetic activity. Signs include a sudden rise in blood pressure, pounding headache, flushing and sweating above the lesion, nasal congestion, and often bradycardia.
- Action: Stop treatment, sit the client upright with legs lowered, loosen anything tight, look for and remove the trigger (check the catheter and drainage bag), and call 911 if symptoms do not settle quickly. Many clients carry an autonomic dysreflexia wallet card.
- Modifications: Inspect skin, reposition regularly, avoid heat and cold where sensation is absent, use gentle range of motion to limit contractures, and avoid forcing joints that may have heterotopic ossification.
5. Progressive and Degenerative CNS Conditions
| Condition | Key features | RMT considerations |
|---|---|---|
| Multiple sclerosis (MS) | Autoimmune demyelination of CNS white matter; relapsing-remitting course in most people at onset; fatigue, spasticity, sensory changes, optic neuritis, Lhermitte's sign | Avoid full-body heat because symptoms worsen temporarily when body temperature rises (Uhthoff's phenomenon); schedule shorter sessions when fatigue is high; avoid treatment during an acute relapse until medically managed |
| Parkinson's disease | Loss of dopaminergic neurons in the substantia nigra; TRAP: resting Tremor, Rigidity (lead-pipe or cogwheel), Akinesia/bradykinesia, Postural instability; shuffling, festinating gait | High fall risk; orthostatic hypotension from the disease and from medication; slow transitions; rhythmic, gentle mobility work; plan sessions when medication is working ("on" periods) |
| Amyotrophic lateral sclerosis (ALS) | Progressive degeneration of upper and lower motor neurons; weakness, fasciculations, spasticity, dysphagia; sensation and bladder control usually preserved | Comfort-focused care; careful positioning for breathing and swallowing; avoid fatigue; coordinate with the care team |
| Cerebral palsy (CP) | Non-progressive brain injury before, during, or soon after birth; spastic type is most common | Address spasticity and contracture risk with slow, sustained techniques; communicate directly with the client and involve guardians as consent requires |
| Dementia (including Alzheimer's disease) | Progressive decline in memory, language, judgment, and function | Assess capacity to consent; keep routines familiar; short, calm sessions; never leave a confused client alone on the table |
| Post-polio syndrome | New weakness, fatigue, and pain years after recovery from poliomyelitis | Avoid fatiguing previously affected muscles; gentle, paced treatment |
6. Peripheral and Acute Neurological Conditions
- Peripheral neuropathy: Diabetes is the most common cause in Canada. A stocking-glove sensory loss means hot and cold applications and deep pressure must be avoided over numb areas (see 5.4).
- Guillain-Barré syndrome (GBS): An acute, usually post-infectious, immune attack on peripheral nerves that causes ascending, symmetrical flaccid weakness with areflexia, sometimes with breathing difficulty. Suspected GBS is a medical emergency. During recovery, treatment is gentle and avoids fatigue.
- Bell's palsy: A lower motor neuron facial palsy that includes the forehead (see 4.1).
- Seizure disorders (epilepsy): Ask about seizure type, triggers, and warning signs. If a seizure occurs, protect the head, move hard objects away, do not restrain the person or put anything in their mouth, time the seizure, and roll them into the recovery position once the jerking stops. Call 911 if it lasts more than 5 minutes, if a second seizure follows, if it is a first seizure, or if the person is injured, pregnant, or has trouble breathing afterward.
7. Clinical Vignette
A 58-year-old client with a T4 complete spinal cord injury is receiving massage to the shoulders while lying supine. He reports a sudden pounding headache, his face is flushed and sweaty, and his radial pulse has slowed. The therapist recognizes autonomic dysreflexia, stops the session, sits him upright with his legs lowered, loosens his waistband, checks his catheter tubing (it is kinked under his thigh) and straightens it. His symptoms ease over the next few minutes. Because autonomic dysreflexia can recur and can cause stroke or seizure, the therapist documents the event and advises him to inform his physician; if the headache had persisted, the therapist would have called 911.
Important
Neurological emergencies in the treatment room are recognition questions: FAST for stroke, upright positioning and trigger removal for autonomic dysreflexia, time-and-protect for seizures, and urgent referral for rapidly ascending weakness.
A client with a C6 spinal cord injury suddenly develops a severe pounding headache, flushed sweaty skin above the injury, and a slow pulse during treatment. What should the therapist do first?
Give the client a sugary drink and observe for 15 minutes, because these are the warning signs of hypoglycemia
Apply a cold compress to the forehead and resume the session at lighter pressure, because these symptoms indicate an ordinary tension-type headache
Lay the client flat with the legs raised to restore blood flow to the brain, then continue treatment once the headache settles
Sit the client upright with legs lowered, loosen tight clothing, and check for a trigger such as a kinked catheter, calling 911 if symptoms persist
A client with relapsing-remitting multiple sclerosis asks for a hot pack across the back before massage. Which response best reflects safe practice?
Apply the hot pack as requested, because heat reduces spasticity and is the preferred modality for every client with MS
Apply ice packs to the whole spine for 30 minutes, because cold permanently halts the demyelinating process
Explain that heat can temporarily worsen MS symptoms, and use a neutral or cool approach with shorter, paced treatment
Refuse all massage, because multiple sclerosis is an absolute contraindication to manual therapy at every stage of the disease
Which set of findings is most characteristic of Parkinson's disease?
Mixed spasticity and fasciculations with intact sensation and progressive difficulty swallowing
Resting tremor, lead-pipe or cogwheel rigidity, slowness of movement, and postural instability
Facial paralysis that includes the forehead, sudden in onset and limited to one side of the face
Ascending symmetrical flaccid weakness with absent reflexes developing over days after a viral illness
A client with epilepsy begins a generalized seizure on the treatment table. Which action is correct?
Hold the client's arms and legs firmly to stop the movements and prevent injury until the seizure ends
Pour small sips of water into the client's mouth as soon as the jerking slows to prevent dehydration
Protect the head, clear hard objects, time it, and call 911 if it lasts more than 5 minutes
Place a rolled towel between the teeth so the client cannot bite their tongue
Sections you finish are checked off in the contents.