MY PROFESSIONAL EXPERIENCE WITH NEUROLOGICAL REHAB: AN ADDRESS TO THE CAYMAN PUBLIC by Resean Reece, Registered Physiotherapist
stance position without assistance. Tasks and obstacles are posed in the patient’s environment to facilitate them manipulating them without swaying, losing balance or falling. This is usually done with the necessary guarding and safety precautions. Balance training is best paired with core and postural exercises to stimulate and strengthen the same muscles responsible for keeping us upright and stable when we reach outside of our base of support. Electrical muscle stimulation (EMS) is popular for stimulating or improving the contraction of weak muscles. Our nervous system functions by electrical impulses being sent between the brain, spinal cord, muscles and internal organs, or what I like to term ‘bioelectricity’. With a disease or injury interrupting such signals, it is understood how an outside stimulus or circuit will directly affect the target body part, acting as a bypass to the damaged nerves. EMS can be applied to virtually any skeletal muscle that is wasted, weak or has abnormal tone, even to facial muscles. The intensity of the current is increased until desired twitches or contractions are observed, but still bearing in mind the patient’s pain threshold. Pain management is sometimes necessary for patient who suffer from inflamed sensory nerves or resulting joint and muscle contractures due to their condition. Nerve stimulators, hot/cold packs and ultrasound therapy are few modalities that can help to control pain. Range of motion and isometric exercises are a concern of the patient, with the misconception that they always make the pain worse. It will be initially uncomfortable but can improve tissue adaptability and blood flow to help the patient to sense less discomfort. Sometimes the simplicity of massage or stretches is all that is needed to relax a painful or tight area. With a patient being wholly immobilized or have at least a paralyzed limb, the biomechanical law has to be observed: ‘if you don’t use it, you lose it!’ Contractures (shortening/tightening) of joint and muscle, wasting (loss) of muscles and decrease in bone density are inevitable, especially if rehab is delayed, or limited attention is put on counteracting them. Frequent stretches would have to be done for the patient, and promoting weight bearing through affected limb to reduce bone mineral loss. Other complications of immobilization such as bed sores and chest infections can be prevented or managed with the help of the physiotherapist, usually through mobilization or appropriate manual techniques. For children being affected by neurological diseases too, such as Cerebral Palsy, Down Syndrome and Spina Bifida, a more playful and creative approach has to be taken towards rehabilitating this special cohort. Video games, puzzles, painting, and ball games can be incorporated in their treatment in order to get their desired focus and movement patterns. More patience is usually required.
Practicing physiotherapy for the past 5 years has exposed me to the treatment of numerous neurological conditions. The nervous system is responsible for cognition, movement, sensation and autonomic functions, such as breathing, digestion, egestion/excretion, cardiac/circulatory functions etc. Neurological conditions can be diseases or disorders affecting the health or function of the nervous system. Examples of such conditions are Strokes, Spinal Cord Injuries, Guillain-Barre Syndrome (GBS), Myasthenia Gravis (MG), Multiple Sclerosis (MS), Neuromyelitis Optica (NMO), Parkinson’s Disease (PD), Traumatic Brain Injures (TBIs), Amyotrophic Lateral Sclerosis (ALS) and Brain/Spinal Cord Tumours. With over 600 diseases of the nervous system present (University of California San Francisco Health), no matter the rarity or onset, it is expected that there will be some degree of cognitive, sensory or motor/physical impairment. I appreciate that I have an integral role in the management and rehabilitation of the affected population, to restore function, mobility and improve one’s quality of life. Actually, it was when I was a second-year physiotherapystudent I fell in lovewithNeuroanatomy and Neurophysiology courses, which broke down how the brain, spinal cord and extending nerves worked together to form the nervous system. My passion for physiotherapy became steadfast when I realized how rehabilitation retrained my patients to walk and even feed themselves, functions lost that the unaffected population takes for granted. In the Beginning... Getting an affectionately called ‘neuro patient’ with a neurological diagnosis for the first time would prompt me to run a background check on their pathology, onset and course of condition, initial medical intervention or rehab and even other existing chronic illnesses they may have. Taking a proper medical and disease history indicates how a patient became ill or debilitated, necessary tests done to confirm or suspect a diagnosis, how they responded to prior treatment and if already existing conditions will contraindicate or complicate rehab. History taking in the initial session helps to form a picture to me of how much the patient is affected and how much they might benefit from this service. Physical Examination The next step in the initial interaction with a neuro patient is testing mobility, function, sensation, joint
and muscle flexibility, muscle strength, balance, coordination, bed mobility and muscle tone. Their level of independence must be established, in self- care activities (e.g. bathing, dressing, toileting and grooming hair) and transfers (e.g. moving between wheel chair and bed or toilet). Specific grading or rating tools or scales are usually used to better indicate the severity of impairment and allow for tracking of progress and reassessment in the following weeks or months. Description of posture and gait (walking pattern) help in identifying the overuse or under-use of associated muscles. Examining a patient will highlight which functions are affected, what type of treatment is necessary and how much improvement will be required for gain of adequate functionality. Non-physical attributes have to be assessed too, such as memory, attention span, speech, mood/personality changes and ability to follow commands, all of which will impact patient-therapist communication. Through a neurological examination, I may find partial or complete weakness to be the primary complaint, involving one limb, two or all four. I have had unique cases where patient has good muscular strength, but due to tremors or rigidity of limbs, they have difficulty initiating following through or stopping movement. A patient can also have good limb strength but poor stability or balance in staying stationary or moving. The greater the neurological damage, the greater the deficits patients will have. It is important to identify how these specific problems affect their daily life or function. For example, I recall a young woman with one sided weakness from a stroke, who was unable to work, drive or take care of her children. Treatment Based on the problems outlined, different treatment protocols or interventions can be used to improve a patient’s health and functionality. The bulk of rehab for strengthening weak muscles, involves the traditional use of weights, resistance bands and exercise machines, however alternative methods have tobeconsidered,suchashydrotherapy (moving with the support and resistance of water), mirror therapy, and game simulators or virtual therapy. The use of music and group exercise can make treatment more fun. These diversifying methods help to make physiotherapy more interesting and poses new stimuli for neuromuscular growth. Balance training is done for those who have decreased stability in doing activities in sitting or standing, or worse, maintaining a seated or
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