Research Grant Through MRS of Dr. Nandu Chhabria PT. is the Principal Investigator on a Research project funded by the MRS - Medical Research Society of Sir H N Hospital. The Subject is Brain Dysfunction - milestones and NEUROANATOMICAL Study. Growth and development has been until now studied in terms of milestones. In fact growth is not linear, but simultaneous in all areas of Sensory Motor function. It is dependent on neural network maturation. Every network has its peak velocity period of maturation resulting into milestones. Experiments have shown that if the peak velocity period is not utilized then the networks function is diminished throughout life. Keeping the above said in mind, this study will be conducted on children with Brain Dysfunction in the age group of 0-5 years. This study will evaluate delayed milestones and developmental age by standardized tests like Gazelle Developmental Quotient AND network maturation and pathway analysis, clinically. A comparative study of treating children with conservative methods and stimulus specific therapy will be studied. Brain Dysfunction- Milestones and Neuroanatomy. Principal Investigator :- Dr. Nandu Chhabria Trustee- Founder Chairman- POSAT foundation- Estd. 1978. Founder President MMI ( Manipulative Mobilization India ) in technical collaboration with IFOMT ( International Federation of Orthopedic Manipulation Therapists ) Co- Investigators:- Ms. Geeta Dalal ( P.T.)- Chief, Dept. of Physiotherapy, Children's Orthopedic Hospital, Ms. Maya Nanavati ( O.T.)
- Incharge, Dept. of Occupational Therapy, Ms. Poonam Bajaj ( P.T.) : Voluntary
Registrar, Dept. of Physiotherapy, CSR is based on Neuroanatomical analysis of Brain-body dysfunction.
Cortico-Subcortical relay is defined as human development and movement is the result of timely integrated Cortico-Subcortical relay. CSR dysfunction in trauma and growth disorders causes mal-develoment and movment dysfunction.
· Age group - 5 months to one year. High Risk Babies : · Head tilted to left side Case C Case D |
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* Challenging the vestibular system, by |
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* Reducing gamma activity in calf muscle |
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* Despite being neurologically normal, head |
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A |
B |
C |
* Age group |
1yr-3mth |
2yrs-6mths |
5-6 years |
*Diagnosis |
*Hypotonic CP |
Spastic Quadriparesis |
Quadriparesis |
*Birth History |
*Intrauterine hypoxiaCord around the neck*Muconium Aspiration |
*Excessive maternal bleeding at the 6th mth.*Muconium aspiration |
Maternal hypertension6th mth onwardsCord around neck* Was on ventilator for a week |
* Clinical picture |
Total hypotonia |
Hypertonia all 4 limbs |
Fluctuating tone |
*Treatment and *Standing with tuber *was given 'L' splint *ASH splint tohome program |
*Standing with tuber *was given 'L' splint *ASH splint tobearing 'L' splint*Hydrotherapy for body orientation *sitting in a chair with a cutout |
*was given 'L' splint*Now learns walking with posterior steel shank shoes in a walker to provide cerebellar stimulation*Rotation on a swing |
*ASH splint tosupport the trunkin standing thereby providingbasal ganglia assist.*Hydrotherapy for body orientation |
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A |
B |
C |
* Age group |
6 yrs. |
3 yrs. |
6 yrs. |
*Diagnosis |
*Spastic Quadriparesis |
*Spastic Diplegia |
*Quadriplegia |
*Birth History |
-Maternal hypertension at 6th mth,bed rest -Premature-8th mth-hypoglycemia,jaun dice,3rd day -Admitted in NICU -Incubator-1 week.for 1 week. |
Spastic Diplegia -Premature birth-7th month |
*Quadriplegia-Maternalbleeding & pain at 6th mth.-Premature-7th month-Incubator-1 week. |
* Clinical picture |
-hypotonic trunk -flexion attitude both knees_Gravitational Insecuritythough protective arm extension present |
-Convergent squint _Rt. upper limb and and both lower limbs spastic |
Marked lower limbspasticity Lt.>Rt. Severe gravitat-ional insecurity.-Protective arm extension absent |
*CSR analysis |
-poor cerebellar control
bilaterally |
* impaired VOR-Right semicircular canal dysfunction-poor gamma inhibition through cerebellum. |
Otolith dysfunction resulting into gravitational insecurity._Poor basal ganglia cerebellar integration- gamma overactivation due to poor cerebellum |
Follow upAfter 4 months30-04-02 |
Ambulation throughCerebellar maturation(walking with elbow crutches) |
All four limbs alternation due to cerebellar progression (walking with walker) |
Protective extension upper limbs present but delayed.Can stand with thalamic feedback with posterior steel shank shoes |
* Treatment and home program |
A |
B |
C |
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_ Back extension arch with upper limb weight bearing |
_Challenging lt. Vestibular nuclei for head control in midline |
_Mat program using Basal ganglia for spatial orientation. |
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_ Standing against the wall wit vestibular crutches ( External vestibular support to cerebellum with thalamic feedback)_ Single leg balancing with crutch. |
_ VOR for eye movement_Reactions on equilibrium ball_ Walking with posterior steel shank shoes.( for improving ankle strategy for correct spinocerebellar feedback tocerebellum)_ Walking with opposite side trunk lordosis and trunk rotation for weight bearing on other side lower limb.Achieves basal ganglia-cerebellar integration at thalamus. |
-Wieght bearing on hands with arm splints_Rotatory( controlled) movement, semicircular canal bypass for otolith_Standing with L splints spinal support to cerebellum. |
MRS of
A book on Rehabilitation was earlier published
under the Editorship of Dr Nandu Chhabria and
a chapter on STROKE.
RESEARCH: FALLS, NEUROANATOMY
AND
MRI TRACTOGRAPHY,
FIRST TIME IN REHAB
MEDICINE COMPLIMENTING
CORTIOCO- SUBCORTICAL
RELAY THORY: CSR
Study presented at the ISPGR conference, June 2009,
Towards the end it was mooted that it would be very instructive if we could more exactly identify the pathology neuro-anatomically. The new radio-imaging technology of MRI Tractography was used to conduct a pilot study to see if pathological anatomy could be established.
Routine brain MRI was normal but Tractography results showed distinct changes. In three of the four patients who were studied by Tractography, there was evidence of degenerative change in the white matter tracts pertinent to the nuclei involved, consequent to the involvement resulting in the dysfunction. In the fourth patient despite abnormal posturography read-out, showing vestibulo-cerebellar involvement, the Tractograph was normal.
The normal findings in the fourth patient who was a much younger male is puzzling. He was a very athletic individual and his lifestyle involved much training that might be naturally therapeutic to his balance dysfunction. Do Tractography ( pathological ) changes reverse with therapeutic intervention ? Balance clinically improves after rehab intervention. What happens to the pathological lesions? Our theory, at Sir HN Hospital, the authors original contribution, we can restore function by recruiting alternative pathways, by the Cortico-Subcortical Relay theory as it is known for gratifying improvements we get with rehab training. It will be particularly interesting to study these before and after in the coming years.
DISCUSSION
The Posturography evaluation system is validated widely and is considered sufficiently reliable in identifying balance problems. It helps to indicate which is the pathological system of the three involved in balance: visual, somatosensory or vestibular or a combination of these.
But it would be instructive to have investigative evidence of the changes responsible. We considered the available radiological tools: CT Scan and MRI (plain and contrast ) invariably show normal anatomy. PET scan and f MRI have been largely employed, so far only for mental tasks. MRI Tractography is a recent innovation using software which can give images of different white matter tracts in different colours. Normal values and age adjusted values are available for reference.
Changes such as atrophy, thinning, Wallerian degeneration like changes and color changes indicating functional deterioration can be identified. This would give inference about the functioning of the grey matter nuclei these fibers originate from or end in. This is the nearest we can come to visualizing the pathology, ante-mortem and by non-invasive methods at the present time. In our first three cases there was very clear cut pathological process demonstrable in the white matter tracts which also neatly co-incides with Posturography results.
CONCLUSION
Fall prediction and prevention by identifying “Faller” predilection, is an important move towards reducing the considerable morbidity and even mortality among the population with falls.
MRI Tractography is a novel software innovation which brings to life by evidence based demonstration of the altered state of the white matter tracts, the changes in the state of the related nuclei these tracts arise from or end in. CSR is the future in Rehab Sciences.
The study presented
at ISPGR conference, 2009,
FUTURISTIC THINKING:
New Milestone, Dusshera, Oct 17th
2010- Balance Center in depth Clinical Research.
Rehab
Sciences with Balance Master has until now more than 500 evaluations. Balance
Center will study dynamic dysfunction due to Center- of -Gravity and
Center-of-Pressure changes and deviations on foot pressures following balance
dysfunctions.
The
Balance Center will bring to life further the already existing Cortico-Subcortical-Readaptation Approach- a scientific application
to clinical management with the basis of the Cortico-Subcortical
Relay Theory originated with us. This will further be facilitated by Dti studies of MRI Tractography
now underway.
Changes
in the Center of Mass and Center of Pressure is the essential discussion in
Lifestyle, aging and changed physical abilities like muscle weakness, obesity
and loss of vestibular function or cerebellar
changes. Future clinicians cannot neglect this global understanding in
management of pain due to biomechanical resultant disturbances.
Movement
Sciences will undergo a sea of change in clinical research and consequent future
therapeutics in Rehab Sciences.
More on the findings to follow.