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Neurorehabilitation
Professional in charge: Esteban A. Fridman
The Neurorehabilitation Section belongs to the Department of Neurology at FLENI and is represented at both Belgrano and Escobar Centers.
During the 1990s, with the scientific recognition that the brain is not a static organ but, quite the opposite, one that adapts to compensate the damage caused by diverse neurological illnesses, Neurorehabilitation is born. This speciality is devoted to the functional recovery of patients with neurological disorders that originate motor and sensory impairment that affect manual dexterity, gait and balance, deglutition and phonation.
The specialist in rehabilitation is represented by a neurologist who interacts/works with a multidisciplinary team consisting of internists, physiatrists, and highly specialized physical therapists, occupational therapists, and phonoaudiologists. Motor deficits such as hemiparesis, paraparesis, quadriparesis, spasticity, dystonia, dysphagia, dysarthria and altered consciousness states (i.e., persistent vegetative state and minimally conscious state) are the most frequent disorders observed among a large number of neurological illnesses and that at present possess specifically designed treatments.
1. Which is the Neurologist's role in Neurological Rehabilitation?
2. Which are the tools available for the Neurologist in Neurological Rehabilitation?
3. Illnesses that benefit with attention for Neurorehabilitation
4. Clinical services
5. Interactions of the Neurorehabilitation Section
6. Investigation and Teaching
7. Research Projects
8. Professionals
1. Which is the roll of the neurologist specialized in Neurological Rehabilitation?
The role of the neurologist specialized in Neurological Rehabilitation is that of a neurologist oriented to the treatment of the sequels caused by diverse neurological illnesses. He/She works together with the different professionals that make up the neurological disciplines, as is the case of vascular neurology, neuroimmunology, neurotrauma and abnormal movement disorders, among others. If patients with cerebrovascular accidents (CVA) are taken as an example, while the vascular neurologist determines the origin of the CVA (e.g., carotid stenosis, heart clot, etc) and the treatment of the cause that originated it (e.g., carotid endarterectomy, anticoagulation, etc), the neurologist specialized in Neurological Rehabilitation treats the consequences arising from the CVA (motor deficit, gait dysfunction, swallowing disorders, etc). The neurologist specialized in Neurological Rehabilitation therefore treats the sequels produced by these illnesses using the modern advances obtained through the better understanding of human motor control.
Besides, he/she is responsible for managing patients in coma and in minimally conscious states until they are able toenter an appropriate cognitive plan of rehabilitation.
2. Which are the tools available for the Neurologist Specialized in Neurological Rehabilitation?
The tools available for the treatment of diverse deficits due to neurological illnesses are very varied. Many of them have been broadly studied and proven effective, as is the case of the specifically created training with neural bases for sensorimotor recovery, stimulating neuromodulatory drugs and neurophysiological stimulation techniques (see below Neurophysiological Unit of Sensorimotor Stimulation).
3. Illnesses that benefit with Neurorehabilitation Treatment
. Ischaemic cerebrovascular accidents (infarcts).
. Haemorrhagic cerebrovascular accidents (haematomas).
. Traumatic Brain Injury
. Spinal Cord Injuries.
. Multiple sclerosis.
. Parkinson's Disease and Dystonias.
. Postoperative of Neurosurgeries.
. Tumours of the Nervous System.
. Infections of the Nervous System.
4. Clinical Services
1. Neurorehabilitation (Neurology)
2. Spasticity Clinic
3. Neurophysiological Sensorimotor Stimulation Unit
1. Neurorehabilitation (Neurology)
The Neurorehabilitation Section is responsible for:
Functional and diagnostic evaluations of patients with deficits due to neurological illnesses, contemplating both the disorders that originated the sequels and the causative cerebral structural damage.
State-of-the-art treatments for the functional recovery of motor and sensory deficits, based on the appropriate decision of the diverse stimulation techniques currently available, specific training, neurostimulatory drugs and neurophysiological stimulation techniques.
Education and advice to patient and family.
Investigation of new treatment strategies based on neurophysiopathological findings.
2. Spasticity Clinic
Spasticity is one of the most frequent complications in neurological illnesses. Its presence negatively influences the degree of functional recovery in patients with motor and sensory impairment, in whom dexterity is a decisive factor to achieve daily independence.
Definition
The Spasticity Clinic is managed by a multidisciplinary team devoted to the diagnosis and treatment of spasticity, with the aim of improving the patient's quality of life.
General objectives
The general objective is the comprehensive attention of the medical, functional and social problems related with spasticity and associated manifestations of motorneuron hyperactivity. More specifically, the purpose is to improve mobility, to diminish spasms, to facilitate hygiene, displacements, and to increase the range of mobility to articulate and to diminish pain.
Scope
The Spasticity Clinic is directed toward patients and their families or caretakers of patients with spasticity as a sequel of neurological illnesses such as cerebrovascular accidents, traumatic brain injury, traumatic spinal injury, multiple sclerosis, encephalitis, cerebral paralysis, cerebral or spinal cord tumours, Central Nervous System infections, motorneuron disease and other degenerative illnesses of the nervous system. Although the primary objective of the Spasticity Clinic is to offer the patient the maximal functional recovery and independence, in patients with long-term morbid processes, with degrees of severe spasticity and absolute dependence, the underlying benefit of the treatment consists in the reduction of care and costs that such involvement brings about.
The Spasticity Clinic carries out the following:
Functional and diagnostic evaluation of patients with sequels of neurological illnesses and spasticity, taking into account both the illness that originated the sequels and the causative structural cerebral damage.
State-of-the-art treatments for spasticity are oriented to the functional recovery of the patient and / or decrease in attention by the carers, based on the appropriate decision of diverse effective medications (systemic and local) and their association with specific training, neurostimulatory drugs and neurophysiological stimulation techniques.
Orientation for surgical treatment of spasticity.
Education and advice to the patient and family members.
Investigation of new treatment strategies based on neurophysiopathological findings.
3. Neurophysiological Sensorimotor Stimulation Unit
Progress in neurorehabilitation of patients with neurological illnesses is being enhanced by the advent of new stimulation modalities. Electric stimulation of peripheral sensorimotor nerves and transcranial magnetic stimulation, alone or associated to the former, are being used in the induction of functional recovery in patients with neurological sequels.
The objective of the unit is the study and treatment of patients with sensory and motor sequels associated to CVA, spinal cord lesions, multiple sclerosis and skull traumatisms. Within these modalities, the first and currently only effective stimulation treatment for recovery from dysphagia is found, i.e., pharyngeal electric stimulation, which allows speeding up the recovery achieved through conventional phonoaudiological and kinesiological therapy (see Deglutition Clinic).
5. Interactions of the Neurorehabilitaction Section
a. Physical and Occupational Therapy
Physical and occupational therapists are the pillars that sustain the result of the diverse treatments selected by the Neurologist specialist in rehabilitation. In turn, the most modern advances generated in specific training for the recovery of patients with sensorimotor sequels have been originated by the interaction of both disciplines.
b. Internal Medicine and Physical Medicine and Rehabilitation
Quite often, patients with sequels of neurological illnesses suffer clinical complications associated with respiratory malfunctioning. Besides, motor and sensory deficits cause a great extra number of associated neurological problems, such as eschars, heterotopic ossifications in which the combined approach of the neurologist specialist in rehabilitation and both specialities lead to the success of the therapy determined by the Neurologist specialist in rehabilitation.
c. Neurophysiology
Neurorehabilitation requires as an essential complement for the diagnosis and follow-up of most illnesses the use of neurophysiological techniques. The main studies employed are as follows:
Electromyography and study of peripheral nerve conduction.
They are useful in the diagnosis of peripheral nervous system illnesses, primarily responsible for states of disablement that require rehabilitation or they may arise as a complication associated to another illness of the central nervous system or to multiple organic dysfunction that is prone to occur in patients in a critical condition due to multiple causes. Their application is extended to the diagnosis and treatment of spasticity; a state of motor hyperactivity frequently associated to illnesses of the central nervous system.
Transcranial Magnetic Stimulation.
This technological resource has applications both in clinical diagnosis and research. In the first case, it allows a non-invasive evaluation of the operation/condition?/modus operandi of the cerebral structures related with movement control and therefore contributes in the diagnosis of involved afflictions. Likewise, it may evidence and quantify response to treatments. In the research field, transcranial magnetic stimulation has been a key instrument for the study and development of current concepts concerning cerebral plasticity in human beings, on which Neurorehabilitation is largely grounded. Besides, transcranial magnetic stimulation is currently under evaluation as a treatment modality.
Somatosensory, auditory and visual evoked potentials.
The application of a visual, auditory or tactile stimulus usually induces the activation of diverse structures of the nervous system. Such activation is manifested by electric signals that may be captured by special instruments. They are useful for the functional valuation of spinal and cerebral structures involved in the processing of somatic, visual and auditory sensory information.
d. Phonoaudiology, Otorhinolaryngology and Swallowing Clinic.
It is essential for the treatment of two extremely frequent sensorimotor afflictions as dysarthria and dysphagia.
d. Neuroimaging
Advances in Neuroimaging, mainly functional magnetic resonance imaging (fMRI), allow the recognition and management of the diverse central pathologies treated in Neurorehabilitation. Block designed studies or more modern studies of the haemodynamic cerebral response related with precise events are those that at the present time are being carried out jointly with the Neuroimaging Department.
In addition, techniques have also been incorporated for structural diagnosis with highly reliable accuracy as in the case of Voxel Based Morphometry that combines structural with functional data (TMS-fMRI).
6. Research and teaching
The Neurorehabilitation Section at FLENI is currently funded by the National Institute of Neurological Disorders and Stroke, belonging to the USA National Institutes of Health, to carry out an investigation programme for the neurorehabilitation of cerebrovascular accidents. Furthermore, it possesses a grant from private capital for the study of patients in coma.
7. Research Projects
1. Conditioned motor learning in motor recovery following cerebral damage.
2. Effects of transcranial magnetic stimulation in functional recovery of patients with cerebral damage.
3. Neural bases of sensory motor recovery and of motor learning.
4. Effects of peripheral electric stimulation and combination of peripheral and central stimulation in sensory motor recovery from hemiparesis, paraparesis and quadriparesis.
5. Neural bases and effects of peripheral and central electric stimulation in sensory motor recovery from dysphagia.
6. Neural bases and response to dopaminergic agents in severe coma.
Professionals
Esteban A. Fridman, MD.
Claudia Navarro, Grant Managment Specialist, Clinical Coordinator
Mercedes Tamashiro, PT.
Juliana Abalo, OT.
Mariana Bonetto, OT.
Noelia Gollo, OT.
Lautaro Silva, PT.
Marcelo Benestante, PT.
Mirta Villareal, PhD, Physist.
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