Rehabilitation of neurological patients - Causes, symptoms and treatment. MF.

Medical rehabilitation means a system of state, socio-economic, professional, pedagogical, psychological and other measures aimed at preventing the development of pathological processes that lead to temporary or persistent disability, and for the effective and early return of patients and disabled persons to society and to sociallyuseful work. According to the definition of the WHO Expert Committee( 1980), medical rehabilitation is an active process whose goal is to achieve the full restoration of impaired functions due to illness or injury, or, if this is unrealistic, the optimal realization of the physical, mental and social potential of the disabled person, the most appropriate integration in societyMcLellan, D., 1997; Wade, D., 1992).Rehabilitation as an independent branch of medicine began to develop rapidly after the Second World War, in which disability of the population reached unprecedented proportions.

Neurorehabilitation, or rehabilitation of patients with a neurological profile, is actually a section of medical rehabilitation, which, as a branch of science, was formed relatively recently. The first in our country neyrereabilitatsionnoe( recovery) department was established in 1964. In the Scientific Research Institute of Neurology of the USSR Academy of Medical Sciences( currently the Scientific Research Institute of Neurology of the Russian Academy of Medical Sciences) on the initiative of the leaders of the Institute of Academicians N. V. Konovalov and E. Shmidt. At the head of the rehabilitation service of the Institute stood outstanding specialists: prof. LG Stolyarova, ESBeyn, GRTkacheva.

Only in 1996 in Newcastle( England) the first world congress on neurological rehabilitation was held. Currently, these congresses are held regularly every three years. In April 1999, Toronto( Canada) hosted the second and third in April 2002 in Venice, the fourth in February 2006 in Hong Kong. These congresses are held under the aegis of the American society of neurorehabilitation, the world forum of neurological rehabilitation and the German society of neurological rehabilitation.

An unambiguous answer, which contingents of patients and invalids need physical neurorehabilitation in the literature do not exist( Chernikova LA, 2003).Some authors believe that medical rehabilitation should be part of the treatment process for all patients who are threatened with long-term disability, others believe that rehabilitation should be used only for people with disabilities.

In our country, the following were traditionally referred to the main nervous system diseases requiring rehabilitation:

· stroke,

· traumatic brain and spinal cord injuries,

· peripheral neuropathies,

· vertebrogenic neurological syndromes,

· cerebral palsy.

Indications for the rehabilitation of demyelinating and degenerative diseases were considered controversial. By now, the main list of nosological forms has been determined, under which physical rehabilitation should be used. These include:

· stroke,

· head and spinal cord injury,

· peripheral nerve damage,

· cerebral palsy,

· multiple sclerosis,

· Parkinson's disease,

· Huntington's disease,

· motor neuron diseasesamyotrophic sclerosis, progressive bulbar palsy, progressive muscular atrophy),

· hereditary diseases of the nervous system( torsion dystonia, cerebellar ataxia),

· polyneuropathies,

· muscular diseases,

· vertebhereditary neurologic syndromes. Of course, the goals and objectives of physical neurorehabilitation for diseases in which there is a formed neurological defect( such as stroke, head and spinal cord injuries) and for progressive degenerative and hereditary diseases( Parkinson's disease, motor neuron diseases, etc.)are different.

So, for the first group of diseases, which include stroke, trauma of the brain and spinal cord, peripheral neuropathies and plexopathies, vertebrogenic radicular and spinal syndromes, infantile cerebral palsy, the main goal of rehabilitation is to achieve full recovery of impaired due to illness or injury functions, or, if this is unrealistic, the optimal realization of the physical, mental and social potential of the disabled, the most adequate integration of it into society, the prevention of complications ostth and reducing periods, prevention of relapse( mainly 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 goal of rehabilitation is to reduce the main symptoms of the disease, prevent and treat complications associated with decreased motor activity, correction of functional disorders, adaptation to the existing neurological deficit, increased toleranceto physical loads, improving the quality of life, increasing social activity, slowing( less often, suspension) aboutthe progression of the pathological process.

One of the important issues that is widely discussed in the modern literature is the question of evaluating the effectiveness of neurorehabilitation.

In order to answer this question, first of all, it is necessary to correctly assess the level of the consequences of illness or injury in order to develop an adequate rehabilitation program.

According to the WHO recommendations of 1980( World Health Organization, 1980, McLellan DL, 1997, Wade D.B 1992), all levels of the consequences of the disease or trauma are distinguished in all patients, including neurological ones:

The first is the level of neurologicaldamage( defect), such as motor, sensory, tonic, psychological disorders, which are revealed in the clinical picture of the patient's disease.

The second level is disability, to which neurological damage can result, for example, walking disorders, self-care.

The third level of consequences( handicap), includes violations of domestic and social activity that arise as a result of neurological damage and impaired functions.

In recent years, the concept of "quality of life related to health" has been introduced into rehabilitation. Some authors believe that this indicator should be guided by the evaluation of the effectiveness of rehabilitation of patients. Of course, the most optimal is the restoration of neurological damage, but unfortunately, in the clinic of nerve diseases this is not very common. If the rehabilitation of patients with a pathological process that has already terminated( stroke, trauma, infection) is in most cases sufficiently effective, then in case of progressive CNS diseases its effectiveness depends not only on the nature and intensity of rehabilitation measures, but to a large extent on the degree and rate of progression of the disease andfrom the possibilities of pathogenetic drug therapy. Therefore, the basic rehabilitation measures should be aimed at restoring the impaired functions and adapting the patient to life in the new conditions. For neurological patients, training in walking and self-service skills is especially relevant.

However, regardless of the nosological form of the disease, neurorehabilitation is based on principles common to all patients who need rehabilitation.

These principles include( Stolyarova LG, Tkacheva GR, 1978; Kadykov AS, 2003):

· early start of rehabilitation measures, allowing to reduce or prevent a number of complications of the early period and contributing to a more complete and rapidrestoration of disturbed functions;

· Systemativeness and duration, which is possible only with a well-organized stage-by-stage construction of rehabilitation;

· Complexity( application of all available and necessary rehabilitation measures);

· multidisciplinarity( inclusion of different specialists in the rehabilitation process);

· adequacy( individualization of the rehabilitation program);

· social orientation;

· active participation in the rehabilitation process of the patient himself, his family and friends.

· use of methods of control of adequacy of loads and efficiency of rehabilitation.

1. The need for early initiation of rehabilitation in patients of the first group is determined by the fact that in an acute period a number of complications arise, largely due to hypokinesia( thrombophlebitis of the lower extremities followed by pulmonary embolism, stagnation in the lungs, pressure sores, etc.)the risk of development and progression of secondary pathological conditions( such as, for example, spastic contractures of the paretic limbs, pathological motor stereotypes, "telegraphic style" in motor aphase).The early onset of rehabilitation contributes to a more complete and faster recovery of impaired functions. Early rehabilitation prevents the development of social and mental maladjustment, the emergence and progression of astheno-depressive and neurotic states. The majority of studies indicate the importance of early rehabilitation( Stolyarova LG, Tkacheva GR, 1978; Bain ES, etc. 1982; Kadykov AS et al 1997; Kadykov AS, 2003;Feigenson JS, 1981; Anderson, TR, 1989).The use of the method of functional magnetic resonance tomography made it possible to establish that the earlier the rehabilitation measures were initiated, the more actively the processes of functional reorganization of the central nervous system take place, and the previously inactive regions of the brain are included in the performance of impaired functions.

In the case of the second group of patients( with chronic progressive and degenerative diseases), the principle of early brain rehabilitation means the beginning of rehabilitation activities with the appearance of the first symptoms requiring active rehabilitation: motor, coordination, cognitive impairments.

2. Systemativeness and duration of active rehabilitation in patients of the first group is mainly determined by the period of restoration of functions. Restoration of the volume of movements and force in the paretic limbs occurs mainly in 1-3 months after a stroke( Kadykov AS, 1992, 1997, 2003, Kelly-Haues M. e. A, 1989).Spontaneous recovery is most active in the first 30 days, in the future recovery is largely due to rehabilitation measures( Duncan P. W. e.,., 1992).Restoration of walking, self-care, complex household skills can continue throughout the year( Duncan P. W. e., 1992), speech, work capacity, statics( with post-stroke ataxia) observed after a year( Kadykov AS et al., 1992).Systematic rehabilitation can be provided only by a well-organized phased construction of the rehabilitation process. The "ideal" model for rehabilitation of patients with acute brain diseases includes:

Stage 1 - rehabilitation begins in the neurological( angioneurological) or neurosurgical department, where the patient is delivered by an ambulance( in case of a stroke or head injury) or arrives in a planned order( in the case of a benign brain tumor).

Stage 2 - rehabilitation in specialized rehabilitation hospitals, where the patient is transferred 3-4 weeks after the stroke, craniocerebral trauma, operations to remove the hematoma, benign tumor, abscess, aneurysm;The second stage may have different options depending on the severity of the patient's condition:

The first option is that the patient with a full recovery of the function is discharged to outpatient care or to a rehabilitation sanatorium.

The second option - patients with severe motor defect, which by the end of the acute period can not move independently and serve themselves elementary, are transferred to the neurorehabilitation department( the department of early rehabilitation) of the same hospital where the patient has been dulled, or to the neurorehabilitation department of a large city or regional hospital.

The third option - patients with motor defects that can move independently and simply serve themselves are transferred from the neurological or neurosurgical department to the Rehabilitation Center. Here patients are transferred from the neurorehabilitation department( department of early rehabilitation) of the hospital as the possibility of independent movement is restored. Patients with predominantly speech pathology can be transferred to the Centers for Pathology of Speech and Neurorehabilitation.

Stage 3 - outpatient rehabilitation in the conditions of a district or inter-district polyclinic rehabilitation center or rehabilitation departments of a polyclinic or rehabilitation rooms of a polyclinic. Possible forms of outpatient rehabilitation as a "day hospital", and for severe ill patients - rehabilitation at home.

For patients with chronic progressive diseases of the nervous system, the systematic and lengthy rehabilitation means the creation of conditions for carrying out practically step-by-step rehabilitation measures, which is especially important in view of the progressive nature of the disease. Undoubtedly, the precise stage principle of rehabilitation, which is necessary for patients with acute brain diseases, is unacceptable here. Inpatient rehabilitation is required only when the condition worsens, the main emphasis is on various types of outpatient rehabilitation( in rehabilitation departments or offices of polyclinics, in the form of "day hospitals", rehabilitation at home).According to the experience of foreign colleagues, rehabilitation should take place in the conditions of specialized sanatoriums.

Many provisions of the "ideal" model of rehabilitation are taken into account in the Order of the Ministry of Health of Russia from 25.01.99.№ 25 "On measures to improve the care of patients with cerebral circulation disorders" and are described in the book "Stroke. Principles of activity and prevention. Ed. NV Vereshchagin, MA Piradova, ZA Suslina, 2002 ".

The principles of rendering assistance to patients with stroke outlined in Order No. 25 are in line with the recommendations for the management of stroke by the European "Stroke Initiative"( Vilensky BS, Kuznetsov AN, 2004).

3. Complexity of rehabilitation

The complexity of rehabilitation is determined by the variety of consequences of acute brain damage, in which, as a rule, not one but several functions suffer. Rehabilitation of motor disorders may include the following methods:

· Kinesitherapy( physiotherapy exercises);

· Biocontrol with feedback;

· Therapeutic massage;

· Treatment by position;

· Neuromuscular electrostimulation;

· Physiotherapy methods( including acupuncture) for spasticity, arthropathies, pain syndromes;

· Household rehabilitation with elements of occupational therapy( abroad - occupational therapy, ergotherapy);

· If necessary, orthopedic measures.

Rehabilitation of patients with speech impairment includes psychological and pedagogical studies conducted by a specialist in the restoration of speech, reading, writing and counting, in which the role of speech therapists-aphasiologists, less often neuropsychologists-is used in our country. Psychologists need help when rehabilitation of patients with emotional, cognitive impairment, patients with post-stroke and post-traumatic neuropsychopathic syndromes. Rehabilitation should be conducted against the background of adequate drug therapy, in the appointment of which, if necessary, therapist, cardiologist, psychiatrist, urologist participate.

4. All this causes multidisciplinarity - participation in the rehabilitation process along with a neurologist of specialists of different profiles, including:

· Kinesitherapist( specialist in curative gymnastics);

· Specialist in biocontrol with feedback;

· Masseur;

· Acupuncture therapist;

· Instructor for household rehabilitation( ergoterapevta);

· Speech therapist-aphasiologist;

· Psychologist;

· Psychotherapist( psychiatrist);

· Neurourologist;

· The sociologist;

· Rehabilitation nurse.

Rehabilitation institutions( inpatient and outpatient) should have the following functional units:

· Kinesitherapy( department or group in the physiotherapy unit) with a gym, preferably with cabinets for bio management and household rehabilitation;

· Physiotherapeutic department with rooms for therapeutic massage, electrostimulation and acupuncture;

· Classrooms of speech therapists-aphasiologists and psychologists;

· Classrooms for functional diagnostics.

5. Adequacy of rehabilitation involves drawing up of individual rehabilitation programs taking into account:

· syndromes to which rehabilitation programs are directed, their severity and individual characteristics;

· Rehabilitation stage;

· Outlook recovery features;

· the state of the somatic sphere and, above all, the cardiovascular system;

· age;

· states of the emotional and cognitive sphere, psychological characteristics of the patient, his family and social status.

It is recommended to establish rehabilitation teams that include a neurologist, a physiotherapist, physiotherapists and physiotherapists, a rehabilitation nurse and, as necessary, specialists from other professions( aphasiologist, psychologist, psychiatrist, ergotherapist, therapist, urologist, etc.)who develop an individual rehabilitation program and monitor the progress of its implementation.

As in cases of rehabilitation of patients with acute brain pathology in the rehabilitation of patients with chronic diseases, the principle of complexity, multidisciplinarity and adequacy( individualization of rehabilitation programs) should be observed.

6. Active participation of the patient, his family and friends in the rehabilitation process.

Clinical experience shows that in those cases when the patient himself is active, his relatives and friends are actively involved in the rehabilitation process, the restoration of impaired functions is faster and more fully. This is largely due to the fact that the practice of kinesitherapy and household rehabilitation, classes on speech restoration take place in a fairly limited time interval: once a day for 40-60 minutes and usually only on working days( ie, 5 times a week).LFK methodologists, speech therapists, ergotherapists give tasks "at home" and the activity of the patient, his relatives( or carers) largely depends on the quality of their performance.

It is necessary for the specialists in kinesitherapy, household rehabilitation, speech rehabilitation to explain the purpose and methodology of the caretakers to the patients caring for the sick, explain the need for such additional classes on the second half of the working day and on weekends.

The decrease in activity, which is often observed in patients after acute brain injury, is associated with the development of various pathological syndromes, including:

· apathy occurring in more than 20% of patients( Starkstein et. A, 1993) and associated with emotional-volitionaland cognitive impairment;

· marked clinical disorders( up to dementia), developed against a background of severe brain damage;

· Neuropsychopathic syndromes - «frontal» and «right hemisphere» syndrome with a decrease in activity up to an incidence with anosognosia( underestimation or negation of a defect);

· asthenic syndrome;

· negativism.

Along with psychotherapeutic and medicamental measures, relatives and close relatives of the patient have a big role in overcoming hypoactivity. In addition to additional training in kinesitherapy and speech restoration, the role of the family in training self-service skills( if they are lost) is already at the earliest stages: eating, personal hygiene, using the toilet, dressing. At the same time, on the part of relatives and friends there is often an inadequate reaction to the patient: in some cases there is a hyperopeak, a warning of every step of the patient, which makes him passive and not an active participant in the recovery process, reduces his self-esteem, in other cases one can meetnegative pessimistic attitude from relatives to the possibilities of rehabilitation, which is easily "assimilated" to the patient himself.

That's why working with the family is an important link in the rehabilitation of patients. It must:

· correct the relationship of relatives with the patient;

· to encourage the patient to take a worthy place in the family in the changed situation;

· to encourage family members to participate in the rehabilitation process.

Rehabilitation specialists should explain to the family and friends of the patient the need:

· bringing the patient to the feasible work for him at home;

· in creating conditions for various occupations( employment therapy), for restoring old and developing new hobbies( hobbies), becauseforced idleness burdens the patient, intensifies depression, apathy and negativism.

The task of rehabilitation specialists is to fully and in detail inform family members about the prospects for recovery and their role in the rehabilitation of the patient. No less important is the principle of active participation of the patient and his family members in the rehabilitation process and for patients of the second group, considering that asthenia, mental and motor hypoactivity are characteristic for the majority of patients with chronic brain pathology, especially as they progress.

7. Use of methods of control of adequacy of loads and efficiency of rehabilitation.

To assess each of the levels of consequences( disruption of the function itself, functional limitations, disruption of household and social activity), diseases in patients with different neurological forms use a variety of different scales and questionnaires. And one of the problems is to standardize these scales, determine their reliability, validity and sensitivity, because only by applying adequate measures of evaluation can you evaluate the effectiveness of the rehabilitation measures