SIG Neurology

According to the World Health Organization (WHO), a stroke is defined as "a sudden neurological deficit of presumed vascular origin."

Two types of stroke can be distinguished:

• Ischemic strokes (75%), caused by an obstruction of a blood vessel by an embolus.
• Hemorrhagic strokes (25%), caused by a rupture of a blood vessel.

Symptoms:

• sudden paralysis or loss of strength in an arm, leg, or half of the face (hemiplegia or hemiparesis)
• sudden loss of sensation in half of the body
• speech disorders (aphasia)
• sudden visual disturbances (hemianopsia)
• intense headaches
• dizziness,
• …

Treatment and management:

Emergency maintenance of vital functions.

Subsequently: Rehabilitation of motor and functional disorders through Bobath, PNF, Perfetti,…

MS is an inflammatory neurological disease characterized by the progressive destruction of the protective sheath (the myelin sheath) of the nerves of the brain and spinal cord.

This destruction (demyelinating plaques) occurs in different locations, which is the cause of lesions in the central nervous system. The disease progresses in relapses and is characterized by dissemination in time and space.

Symptomatology:

• motor: paresis (decreased strength in one or more limbs), cerebellar (coordination disorders)
• sensory: paresthesias, pain, sensory disturbances
• visual: retrobulbar optic neuritis (double vision)
• sphincter

Treatment and management:

Rehabilitation through Bobath, Perfetti, PNF

Parkinson's disease is a degenerative neurological condition in which the dopaminergic cells and neurons located in the substantia nigra of the basal ganglia are progressively destroyed. This dopamine is involved in the control of movements.

Symptoms:

• Classic triad: akinesia-bradykinesia (slowness in initiating and executing movement), resting tremor, and plastic hypertonia (rigidity of limbs)
• Postural instability is added.
• The origin of the disease is multifactorial, involving genetic and environmental factors.
• L-Dopa (or levodopa) is the reference treatment.

With well-balanced and patient-adapted treatment, the patient can lead a nearly normal life

Head injury is defined as an aggression to the brain caused by an external force that can lead to a decrease or alteration in states of consciousness, cognitive and sensorimotor capacities, and physiological functioning.

In the majority of cases, the cause is a road accident and therefore mainly affects young people.

Lesions due to head injury visible on a scan (just after the accident); the following are distinguished:

• focal brain lesions: extradural hematoma
• diffuse brain lesions
• brainstem lesions

Coma characterizes this period. It can be defined as a lasting disorder of consciousness, vigilance, wakefulness function, and other functions of relational life, associated with disturbances in the regulatory mechanisms of vegetative life.

Management during the coma period

The injured person is in intensive care (vital prognosis at stake). Lesions that may threaten survival or functional future (fractures..) benefit from specific treatment. Management is targeted at preventing complications. In this constraining environment, the physiotherapist participates in nursing and endeavors to maintain the best possible orthopedic state to safeguard functional future. Although mortality is highest in the first few days, a certain number of patients are likely to remain in a state of chronic coma and cannot progress to the wakefulness stage.

Management at the wakefulness stage

Continuation of nursing and neuro-orthopedic rehabilitation. Either persistence of deficits due to irreversible lesions or recovery through reactivation of the lesioned territories will be encountered. It is necessary to guide the physical and intellectual autonomy of the injured person by intervening during privileged moments of wakefulness and respecting the rest periods of a fatiguable and disorganized patient. It is the careful observation of the subject's spontaneous activity that should guide his management, more than directed activities, often inappropriate, too complex and harmful: it is necessary to identify the impossibility of perceiving and integrating visual or auditory stimulations and messages, perseverations on instructions and their immediate forgetting, to adapt the relationship with the injured person, in a period where one cannot count on his collaboration.

Main wakefulness patterns (modes of emergence from coma)

• motor deafferentation syndrome: locked-in syndrome: the patient presents with quadriplegia and facial diplegia (bilateral facial nerve involvement) without lateralization of gaze; consciousness may be almost complete with establishment of a communication code with the subject.
• akinetic mutism: eyelid blinking is observed in response to threat, and conjugate eye movements. The neurological examination is "normal", but no instructions can be executed. In the complete form, the patient is immobile, unable to communicate and feed themselves.
• Post-traumatic confusion: it manifests as clouding of consciousness (Glasgow between 8 and 15): perceptual anomalies, disorganization of thought, increased psychomotor activity.
• Post-traumatic amnesia: forgetting as it happens, temporospatial disorientation, non-recognition of relatives. The neurological examination may, otherwise, be normal.

Evolution of neurological deficits

The most frequent possible impairments affect:

• the cranial nerves
• the central nervous system (brain, cerebellum, brainstem…). These impairments are expressed by:
• hemiplegias: all their clinical forms are possible (depending on the level of impairment of the motor pathways), they are either unilateral, or bilateral, and more or less severe;
• abnormal movements, uni- or bilateral, more or less severe, either involuntary, or due to disorders of voluntary movement (cerebellar syndrome, dyskinesias).

Evolution of neuropsychological deficits

• language disorders: they can be located at different levels, be afferent (perception and comprehension) and/or efferent (expression);
• attention disorders: they can affect the different types of attention, and are extremely frequent;
• memory disorders: affecting short-term memory (recent facts) or long-term memory (ancient facts);
• perceptual disorders: they are essentially visual and concern the recognition of objects, images, writing or physiognomies (the subject sees but does not recognize what he sees)
• praxic disorders: a number of subjects have difficulties in performing gestural sequences or reproducing geometric figures while they do not have a motor deficit;
• executive function disorders: in this case, it is the planning of actions that is impossible or disrupted.

The Bobath Concept is a neurotherapeutic approach to assessment and treatment based on the resolution of functional therapeutic situations. It is based on the fact that a brain lesion is responsible for an exaggeration of reflex systems by the lifting of central inhibition, leading to a disturbance of postural tone making the elaboration of voluntary gesture and skilled gestures impossible. The goal is to optimize function, therefore, functional independence and quality of life, by improving postural control and selective movements, for example through facilitation.

Principles of specific treatments:

Maintain physiological joint amplitudesRegulate tone (weight bearing, inhibition, activity)Maintain joint alignment throughout the activityStimulate perception, especially tactile and kinesthetic (touch, movement, posture)Stimulate righting reactions. Train motor control, strength, coordination, endurance. Train balance. Train walking rehabilitation.

Proprioceptive neuromuscular facilitation is a method where one tries to normalize the disturbances in the course of a movement. To achieve this, the pressure and stretch receptors in the muscles, but also the tendons, joint capsules are stimulated. This is done through a precise sequence. The muscle's reaction will be a stronger contraction or relaxation. It is characterized by complex movement patterns, which mainly run in diagonal patterns. The summation of stimuli, tactile or proprioceptive, is crucial in the PNF method, in order to achieve an optimal result.

Objectives:

Regulation of tone (inhibition of spasticity, or facilitation of hypotonic muscles)Stimulation of motor controlStimulation of mobilityStimulation of dynamic stability, endurance, strength. Stimulation of coordination and fine motor skills.

In "cognitive therapeutic exercise", the goal is the adaptability of the functional system, the reorganization of the central nervous system. The basis of the therapy is tactile sensitivity, which plays a primordial role in the organization of movement. The exercises are always performed with the patient's maximum conscious concentration, who is asked to solve a cognitive problem. They are divided into three degrees. The first degree consists of controlling the reactions to stretching for better relaxation. The patient keeps their eyes closed and is passively guided by the therapist. Through their perceptual hypothesis, the patient expresses their feelings by describing the movement performed.

In the second degree, we move on to active-passive mobilization. The patient therefore has a voluntary movement while controlling the irradiation. The third degree will be trained when the patient can perform the movement in its full amplitude. The eyes are open and endurance and speed can be worked on.