Research Grant Through MRS of Sir H N Hospital

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.
Sponsored by Sir Hurkisondas Nurrotumdas Medical Research Centre, Mumbai-400004.

Principal Investigator :- Dr. Nandu Chhabria
Author : 'CSR' Theory
Honorary Director Rehab. Sciences,
Sir H.N. Hospital, Mumbai-400004

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,
Haji Ali, Mumbai-400034.
Co-chief, Dept. of Physiotherapy, Sir H.N. Hospital, Mumbai -400004.

Ms. Maya Nanavati ( O.T.) - Incharge, Dept. of Occupational Therapy, Sir H.N. Hospital,Mumbai-400004.

Ms. Poonam Bajaj ( P.T.) : Voluntary Registrar, Dept. of Physiotherapy, Sir H.N. Hospital, Mumbai-400004.

"CSR"
( Cortico-subcortical Relay )
A theory by Dr. Nandu Chhabria.

CSR is based on Neuroanatomical analysis of Brain-body dysfunction.


It emphasizes the importance of connecting neuronal network for recovery. The grey matter being the interneuronal elements.


Utilization of dormant potential pathways in therapeutic management for restoration of function in cases with dysfunction ( due to any cause ) in Rehabilitation Sciences is the CSR thinking.

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.


Milestone of -
· Head control to walking
· Gross Motor movement to fine skillful action.
· Cooing to babbling to speech and language development.
· Cognition to conceptualization to reading and writing,
Are the mirror images of the mileage covered by the Cortico-Subcortical neurons in precise timing during maturation.
The development is not linear, but, is simultaneous in all areas depending upon network maturation.
Every network has it's peak velocity period of development. Various studies on newborn animals and human fetuses have proved that specific stimulus facilitates a particular pathway formation. Peak velocity period of a pathway if not utilized with the right kind of stimuli repeatedly, then, that pathway function remains defective throughout life. This pilot study of Brain Dysfunction-Milestones and Neuroanatomy aims at -
Studying the CSR approach targeting at prevention of pathway atrophy and facilitating the timely formation of developing network through the right stimuli in children wit brain dysfunction an also analyses the conservative methods of activating milestones through postural mechanisms such as righting reactions and balancing reactions aiming to get postural stability and correct pattern of movements.

CASE HISTORIES

· Age group - 5 months to one year.
· Diagnosis -A-B- High Risk Babies- two
C - Spastic Diplegia - One
D - Phocomelia - One
· Birth History - Prematurely born at the 7th or 8th Month
- Were put in the incubator for a month
- Referred for early intervention.
· Clinical Examination-
Audio-Visual responses - Age appropriate

High Risk Babies :
Cases A-B
(Both similar clinical picture)

· Head tilted to left side
· Spasticity of left upper and lower limb indicating vestibular apparatus dysfunction
· Case A- Trunk hypotonia Case B- Trunk tone - normal, Basal ganglia
Maturation complication
CSR Analysis
As none of the four has history of foetal distress the basal ganglia have formed as a cell station in early weeks of intrauterine life. The vestibular system which starts developing in the last trimester, is the main system affected semi-circular canal dysfunction, Left > Right.

Case C
Also had a history of birth asphyxia, was on oxygen for ten days-thus spastic diplegic

Case D
A case of Phocomelia - Despite being neurologically normal, he does not have arms to weight bear and hence shows delayed development of the vestibular system and therefore delayed head neck control, and rolling. This shows that even if the lesion is similar, and the pathway hit is the vestibular pathway, still the clinical picture of every child differs depending on natural reorganization.

 

· Treatment planning and Home program :-

 

A& B
Age 5-10 months

* Challenging the vestibular system, by
   Retracting the right shoulder, bringing
   The head to the midline automatically.
* Activating the VOR bilaterally for vest-
   ibular system and eye control through
   cerebellar head neck stimulation.
   Both the above encourage head and neck
   control
* Mat program through basal ganglia
   activation
* Equilibrium reactions on the vestibular
   ball
* Sitting in a plastic tub- tilting the tub in
   any direction for activation of spatial
   orientation through the vestibular
   system.
* Supported sitting in a chair with tray to
   encourage forearm weight bearing to
   activate the vestibular system through the
   pacinian corpuscles of the elbow joint.

 

Case C- Spastic Diplegia
(10 months)

* Reducing gamma activity in calf muscle
   and tendoachilles relaxation - pressing the
   ball with heels to activate dorsiflexion, thus
   also challenging the vestibular system for
   upper limb control and stimulating lower
   limb control ( Vestibular nuclei and
   dorsiflexion connection)
* Standing on a Dunlop pillow with proper
   position of the feet ( support of the therapist)
* Standing with tuber bearing L-splints at
   home ½ hour four-five times per day. Ankle
   strategy.

 

Case D- Phocomelia
4 months

* Despite being neurologically normal, head
   control is delayed as arms cannot be used for
   weight bearing.
* Rocking in air with support of the and at the
   back of the head.
* Activating head lifting in prone position.
   Using optic reactions and encouraging head
   and neck control.
* Mat program for basal ganglia network
   development and maturation.
* Reactions on the vestibular ball.
* Similar grey cell lesions but different
   pathways are affected and a completely
   different clinical picture is manifested in each
   case.
* Tailor made treatment.

 

 

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

 

 

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
*poor vestibulo-cerebellar integration

* 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

 

_ 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.

 

_ 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 Sir H.N Hospital has alreaady published a brochure on CSR.

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, BOLOGNA on the above subject was very welcome.

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.

 

India’s contribution to the International world will not go unknown with furthur investigations in the Pathway Bypass management guided by MRI tractography and clinical research, demonstrating Neuron to Neuronal network utilization for limiting dysfuntion in many areas of management both in Neurological and Orthopaedic problems yet unsolved. The Horizon remains to be umlimited

 

 The study presented at ISPGR conference, 2009, Bologna was by Dr. Poonam Bajaj, Co-investigator and Dr. Nandu Chhabria, Chief Investigator, Hon Director, Rehab Sciences, Sir H.N. Hospital & Research Center.

 

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.