Case Studies
CASE STUDY 1: BASILAR ARTERY THROMBOSIS
Mr."A"54 year old male, successful businessman in general good health, was suddenly hospitalized 7th June 1994.
Inability to move left side of the body with slurring of speech. No history of giddiness, vomiting or convulsions. Past Medical History: Significant for Hypertension of 5-6 years duration, on irregular treatment regime.
Few hours after admission noticed loss of consciousness with total body
paralysis.Tracheostomy and ventilation support provided in the ICU for two months. Passive Physical Therapy maintenance and nursing with good acute care followed until 20th March 1996.
MRI FINDINGS: on admission revealed an area of gliosis in the left occipital lobe. Basilar Artery thrombosis.
Follow up MRI Findings 29th June 1994 presented a non-heamorrhagic infarct in the pons more on the right.
'CSR'-Cortico-Subcortical Relay evaluation by Dr.N.D.CHHABRIA as late as post cerebral Insult 2 years and 4 months.
Findings :
Trace movement (R) UL, Nil movement (L) UL.
Nil Head Neck and Trunk control.
Presence of Bilateral LL extensor thrust.
No Speech.
And totally dependent activities of daily living.
BYPASS was aimed at Spinal extensor mechanism. Spinal Reflexes were stimulated with standing assisted by ankle strategy lock with the help of boots and posterior steel shank. As the extensor thrust improved trunk reactions were added to integrate Basal Ganglia pathway interactions. Visual cues were a great help.
After intensive stimulation in this direction for 1 year Cerebellar pathways were initiated with knee supports, AFO's and Lumbar-Hip complex fixation with leather loops. Postural reactions improved tremendously. Left Cerebellar pathways were more reactive. Asymmetry was thus established and spastic symmetrical reactions broken. As balance improved VOR Vestibular Ocular Reactions in sitting and standing were intensified. Basal Ganglia improvement was still more rapid.
One has to start somewhere in the CNS (Central Nervous System) and proceed towards the major lesion.
EVERYTHING IS CONNECTED TO EVERYTHING ELSE. DETOUR FOR FUNCTION THEREFORE BECOMES MANDATORY.
MRI 10th February 2000 Reveals consolidation of the infarct.
Infarct consolidated. Improvement noticed in the form of 2man assist ambulation and independent sitting with supervision. Integrated head neck postures and some vocal cord reactions with improved spatial orientation, indicating white matter interaction in the presence of gray matter lesion consolidation.
Since 3 months he has attended regular office in his specialized transport van and post lunch regular therapeutics at the clinic. Status of voluntary movements today, has a good initiation in the (R) UL, somewhat less in the (L) and active knee extension (R) more than (L). The whole attitude of the patient has changed. He is more reactive, alert and responsive, communicative with a strong sense of humor which spreads happiness all round.
ANALYSIS OF PATHWAY DYSFUNCTION AND CORRELATED NEUROANATOMICAL MANAGEMENT IS THE GOAL AND AMBITION OF FUTURE REHABILITATION.
For over two years patient was otherwise passive but the potential existed.
Pathway Coactivation Was the Essential Key.
CASE STUDY 2: REAR ENDED COLLISION WITH LBP
Ms."B" 28 year old female computer analyst presents with a
history of rear-ended collision. The jarring effect ended in severe
low back pain with burning sensations in the soles of the feet. Conservative
treatment did help but left her totally handicapped due to recurrence
in pain, giddiness, imbalance, sway in standing, scoliosis and marked
abdominal weakness.
We have begun to introduce CSR principles in Manual Medicine also under
the unit "MMCS " - Manual Medicine Cortico Subcortical.
On examination in this direction we were flabbergasted to hear a previous
history. Episodes of high-grade fever in childhood and imbalance during
growth and development. Thus the history of Semicircular canal irritation
and giddiness post accident. The Vestibular pathways were tremendously
affected (L) more than (R) The patient preferred broad base gait and
this has been consistent during her life. With the VN (Vestibular Nucleus)
dysfunction, the patient found it very difficult to restore balance
on backward tilt.
We rightly concluded that the nervous system was highly contributory
to the orthopedic problems of low back pain, or other Orthopedic conditions
not responding to Conservative or Manual Medicine programs alone. Results
were satisfactory if the neurological aspect was also tackled. The BYPASS
used was posture at the Basal Ganglia level. Postural Rehabilitation
and Equilibrium program was initiated.
Within two months the low back pain almost disappeared. The feeling
of sway and low back pain, which was otherwise a great concern to the
patient, was completely under control. It was not a time factor. It
was definitely tackling the cause of Neural Dysfunction resulting in
protective reactions and spasms with resultant LBP treated but not pain
free.
MMCS will now evaluate more cases of this type and prepare a
concise report on this very important aspect of Rehabilitation Medicine.
CASE STUDY 3: LEFT FRONTAL ASTROCYTOMA
Name: A.S.
Status as on 27th May 2002.
Evaluation: Flaccid -> Voluntary movement recovering
Tone: present in pectorals and biceps of the right upper limb
Extensor thrust- present in the right lower extremity.
Flexor chain- good in the right lower extremity.
Speech: sluggish, slurring
Rolling: could roll but right shoulder falls back.
Explanation: Right vestibular nuclei dysfunction keeping the right shoulder
pinned to the bed on attempting to roll right to left.
Vestibular nuclei help in bringing the body forward from a backward
sway.
Management: To make the patient roll use trunk and spine rotation thereby
utilizing the interaction between the basal ganglia of both sides, mainly
trunk musculature.
Thus understanding of CSR-Neuroanatomical dysfunction and bypass is
essential in Rehabilitation management in the future.
Bridging: was possible but right hip could not be elevated as much
as the left hip i.e. oblique bridging.
Explanation: Dysfunction of the right vestibular nuclei
Management: Use the interaction between the supplementary motor areas
of both sides thereby getting good gluteal contraction and therefore
good bridging. Supplementary motor areas work bilaterally, more so in
associated movements.
Sitting: Could not get up to sit as right shoulder was falls back to
the bed. When made to sit the patient tended to fall on the right side.
Management: Once the patient was taught rolling, utilization of the
vestibulo-occular reflex (right) and the head neck posure alignment
to activate the right vestibular system, once the patient reached the
position of side-lying with elbow support further carry over with the
Left cerebellar relays to push up on the left arm to sit up.
Since the patient had a tendency to fall to the right, utilizing the
right Vestibulo-occular reflex corrected this imbalance and the patient
could maintain good sitting balance only through pathway understanding
is this function possible.
Standing and walking: Tended to buckle on the left
Difficulty in initiating walking.
Management: Since the frontal lobe is affected the patient should not
be given too many commands as it confuses the patient, therefore utilize
the unaffected frontal lobe (right) and activities to follow reflexly
or automatically at the spinal levels.
Initiate walking from the left or the unaffected lower limb and the
right or affected limb will follow by alteration
Bypass : Use the right frontal cortex to the left cerebellum and interaction
between right cerebellum and left cerebellum by alternation.
The patient should be assisted, but no direct verbal commands should
be given. Maintain cerebellar automatism.
Right frontal-> left cerebellum-> right cerebellum and
follow through
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