Rehabilitation of neurological patients - Causes, Symptoms and Treatment .MF .
Under medical rehabilitation means a system of public, social, economic, professional, pedagogical, psychological and other measures aimed at preventing the development of pathological processes that lead to temporary or permanent disability, and an effective and early return of the sick and the disabled into society andfor socially useful work.By definition, the WHO Expert Committee (1980), medical rehabilitation is an active process, the aim of which is to achieve full recovery of damaged due to disease or injury functions, or if it is unreal - optimum implementation of the physical, mental and social potential of the disabled, the most adequate to its integration in society (McLellan DL, 1997;. Wade D.B 1992).Rehabilitation as an independent branch of medicine began to develop rapidly after the Second World War, in which the disability population has reached unprecedented proportions.
Neurorehabilitation, or rehabilitation of patients with neurological, is actually the section of medical rehabilitat
only in 1996 in Newcastle (England), the first World Congress on neurological rehabilitation.Currently, these congresses are held regularly every three years.In April 1999 in Toronto (Canada) took the second and the third in April 2002 in Venice, the fourth in February 2006 in Hong Kong.These congresses are held under the auspices of the American Society of Neurorehabilitation, World Forum of neurological rehabilitation and neurological rehabilitation of German society.
single answer, which contingents of patients and people with disabilities need physical neurorehabilitation in the literature do not exist (Chernikova LA, 2003).Some authors believe that medical rehabilitation should be part of the therapeutic process for all patients at risk of long-term disability, while others - believe that rehabilitation should be used only for people with disabilities.
In our country, traditionally the major diseases of the nervous system in need of rehabilitation, attributed:
· traumatic injuries of the brain and spinal cord,
· peripheral neuropathy,
· vertebral neurological syndromes,
· childrencerebral paralysis.
Indications for rehabilitation demyelinating and degenerative diseases were considered controversial.To date, it identifies the main list of clinical entities in which the physical rehabilitation should be used.These include:
· injury of the brain and spinal cord,
· damage to the peripheral nerves,
· cerebral palsy,
· multiple sclerosis,
· Parkinson's disease,
· Huntington's disease,
· disease of the motor neuron (amyotrophic lateral sclerosis, progressive bulbar palsy, progressive muscular atrophy),
· hereditary nervous system (torsion dystonia, cerebellar ataxia),
· muscle disease,
· vertebralneurological syndromes.
course, the aims and objectives of physical neurorehabilitation for diseases in which there is formed a neurological defect (such as stroke, brain and spinal cord injury) and for progressive degenerative and hereditary diseases (Parkinson's disease, motor neuron disease, etc.) are distinct.
So, for the first group of diseases, which include stroke, brain and spinal cord injury, peripheral neuropathy and plexopathy, vertebral radicular and spinal syndromes, cerebral palsy, the main goal of rehabilitation is to achieve full recovery of damaged due to disease or injury functionsor, if this is impossible, the optimal realization of the physical, mental and social potential of the disabled, the most adequate to its integration into society, prevention of complications of acute and recovery period, prevention of relapse (mainly this concerns the prevention of recurrent stroke).
For patients of the second group of diseases, which include progressive degenerative and hereditary diseases of the nervous system, the rehabilitation goal is to reduce the main symptoms of the disease, prevention and treatment of complications associated with a decrease in motor activity, correction of functional disorders, adaptation to existing neurological deficits, increasingexercise tolerance, improve quality of life, increasing social activity, moderation (less suspension) the progression of the pathological process.
One important issue that is widely discussed in the current literature is that of evaluating the efficacy of neurorehabilitation.
To answer this question, it is first necessary to properly assess the level of the effects of illness or injury, in order to develop an adequate rehabilitation program.
According to WHO recommendations of 1980 (. World Health Organisation, 1980; McLellan DL, 1997; Wade D.B 1992) in all patients, including neurological, there are three levels of the effects of illness or injury:
first - itthe level of neurological damage (defect), such as motor, sensory, tonic, psychological disorders, which are identified in the clinical picture of the patient's disease.
second level - a dysfunction (disability), which can cause neurological damage, for example, walking disturbances, self-service.
third level consequences (handicap), including violations of civil and social activity, which arise as a result of neurological damage and functional disorders.
In recent years, rehabilitators also introduced the concept of "quality of life related to health."Some authors believe that it is at this rate should be guided in evaluating the effectiveness of rehabilitation.Of course, the best is the restoration of neurological damage, but, unfortunately, in the clinic of nervous diseases is not observed very often.If the rehabilitation of patients with already ended pathological process (stroke, trauma, infection) in most cases turns out to be quite effective, when a progressive disease of the CNS its effectiveness depends not only on the nature and intensity of rehabilitation, but to a large extent on the degree and rate of disease progression andthe possibilities of pathogenetic drug therapy.Therefore, the main remediation activities should be aimed at the restoration of the disturbed functions and the patient's adaptation to life in the new environment.For neurological patients particularly relevant is the training of walking and self-service skills.
However, regardless of the disease nosology neurorehabilitation is built on the basis of principles which are common to all patients in need of rehabilitation.
Such principles include (carpenter LG, Tkachev GR 1978; Kadykov AS 2003):
· early start of rehabilitation measures, allowing to reduce or prevent a number of complications of the early period and enhances theand rapid recovery of the disturbed functions;
· regularity and duration, which is only possible with a well-organized phased construction of rehabilitation;
· complexity (use of all available and necessary rehabilitation);
· multidisciplinary (including the rehabilitation process multidisciplinary);
· adequacy (individualization of rehabilitation programs);
· social orientation;
· active participation in the rehabilitation process of the patient, his relatives and friends.
· Use methods of control of the adequacy and effectiveness of rehabilitation loads.
1. The need for an early start of rehabilitation patients of the first group is determined by the fact that in the acute period, a number of complications, largely due to hypokinesia (thrombophlebitis of the lower limbs, followed by pulmonary embolism, pulmonary congestion, bedsores and other.)as well as the risk of development and progression of secondary pathological conditions (such as, for example, spastic contracture paretic limbs, abnormal movement patterns, "telegraphic style" with motor aphasia).Early initiation of rehabilitation contributes to a more complete and more rapid recovery of impaired functions.Early rehabilitation prevents the development of social and psychological maladjustment, the emergence and progression of asthenic-depressive and neurotic states.On the importance of early rehabilitation indicates the majority of studies (Carpenter LG, Tkachev GR, 1978; Bain, ES et al 1982. Kadykov AS et al 1997;. Kadykov AS, 2003;Feigenson JS, 1981; Anderson TR, 1989).Application of functional magnetic resonance imaging revealed that started earlier than rehabilitation activities, the more active processes occur functional reorganization of the central nervous system, in the implementation of the disturbed functions previously switched inactive regions of the brain.
With regard to the second group of patients (chronic progressive and degenerative diseases) the principle of early rehabilitation of the brain means the beginning of rehabilitation when the first symptoms that require active rehabilitation: motor, coordination, cognitive impairment.
2. Systematic and duration of active rehabilitation patients of the first group is mainly determined by the period of restoration of functions.Restoring force and range of motion in the paretic limb occurs mainly in 1-3 months after stroke (AS Kadykov, 1992, 1997, 2003, Kelly-Haues M. e. A, 1989).Spontaneous recovery of the most active place in the first 30 days, further recovery is largely due to the rehabilitation activities (Duncan P. W. e. A., 1992).Restoring walk, self-service, residential complex skills can last for years (Duncan P. W. e. A., 1992), speech, disability, static (with post-stroke ataxia) is observed after one year (Kadykov AS et al., 1992).Systematic rehabilitation can only be ensured well-organized phased construction of the rehabilitation process.The "ideal" model of rehabilitation of patients with acute brain diseases include:
Stage 1 - rehabilitation begins in neurology (angionevrologicheskom) or neurosurgical ward where the patient transported by ambulance (in the case of a stroke or traumatic brain injury) or acts in a planned way(in the case of benign brain tumors).
Phase 2 - rehabilitation in specialized rehabilitation hospital, where the patient is transferred 3-4 weeks after stroke, traumatic brain injury, hematoma removal operation, a benign tumor, abscess, aneurysm;Stage 2 may have different options depending on the severity of the patient:
first option - the patient with full restoration of function is discharged for outpatient follow-up care or rehabilitation sanatorium.
second option - patients with severe motor defect that by the end of the acute period can not move independently and elementary care of themselves, are translated into neyroreabilitatsionnoe compartment (early rehabilitation) of the same hospital, which lowered his patient, or neyroreabilitatsionnoe separation of major urban or regionalhospitals.
third option - patients with motor defects, which can move independently and serve themselves elementary transferred from neurologic or neurosurgical department in the rehabilitation center.These same patients are transferred from neyroreabilitatsionnogo compartment (early rehabilitation) hospital as the possibility of recovery of independent movement.Patients with predominantly speech pathology can be converted into centers of Speech Pathology and Neurorehabilitation.
Stage 3 - outpatient rehabilitation in a district or inter-district outpatient rehab center or a rehabilitation clinic offices or clinics reconstruction surgeries.There are such forms of outpatient rehabilitation as a "day hospital" and bad for heavy patients walking - at home rehabilitation.
For patients with chronic progressive disease of the nervous system regularity and duration of the rehabilitation is to create conditions for practical gradual rehabilitation, which is especially important given the progressive nature of the disease.Undoubtedly, there is a clear landmark unacceptable principle of rehabilitation needed for patients with acute diseases of the brain.Inpatient rehabilitation is required only if the deterioration of the focus is on the different types of outpatient rehabilitation (in the recovery wards or offices clinics, in the form of "day care" at home, rehabilitation).According to the experience of foreign colleagues, a certain place should take rehabilitation in specialized health centers.
Many provisions of the "ideal" model of rehabilitation included in the Order of Ministry of Health of the Russian 25.01.99g.№25 "On measures to improve care to patients with disorders of cerebral circulation" and in the book "Stroke.Principles of activity and prevention.Ed.N.V.Vereschagina, M.A.Piradova, Z.A.Suslinoy, 2002 ".
outlined in Order №25 principles of providing care to patients with stroke comply with the recommendations on the management of the European Stroke "Stroke-initiative" (Wilensky BS, AN Kuznetsov, 2004).
3. Complex rehabilitation
complex rehabilitation is determined by the variety of the consequences of acute brain injury, in which, as a rule, suffer from not one but several functions.Rehabilitation of motor disorders may include the following methods:
· kinesitherapy (exercise therapy);
· biofeedback feedback;
· Massage Therapy;
· Treatment position;
· Nervnoomyshechnuyu electrostimulation;
· Physical therapy methods (including acupuncture) for spasticity, arthropathies, pain syndromes;
· Household rehabilitation with elements of occupational therapy (abroad - occupational therapy, occupational therapy);
· If necessary, orthopedic activities.
Rehabilitation of patients with speech impairments includes psycho-educational sessions conducted by a specialist in the restoration of speech, reading, writing and arithmetic, in which the role of our country are usually the speech therapists-aphasiology, at least - neuropsychologists.Psychologists Help is needed in the rehabilitation of patients with emotional, cognitive impairment, in patients with post-stroke and post-traumatic syndromes neyropsihopaticheskimi.Rehabilitation should be carried out against the background of adequate drug therapy, which involves the appointment of a therapist, cardiologist, psychiatrist, urologist if necessary.
4. All this causes multidisciplinary - participation in the rehabilitation process, along with the neurologist specialists in different fields, including:
· physical therapist (physiotherapist);
· Specialist biocontrol with feedback;
· Instructor for home rehabilitation (occupational therapist);
· Speech therapist-aphasiology;
· psychotherapist (psychiatrist);
· rehabilitation nurse.
Rehabilitation Centers (inpatient and outpatient) should be composed of the following functional units:
· kinesitherapy (branch or group of physiotherapy department) with physical culture room, preferably with rooms for biofeedback and home rehabilitation;