Have you ever wondered how neurological rehabilitation actually works? Well, the answer lies in the fact that your brain is divided into several interesting anatomical structures each of which is dedicated to a specific function & with those functions being treated individually, one can achieve the excellence of effective neurological rehabilitation. Here we will be exploring some statistically proven interesting tidbits about neuro rehab that are helpful, practical & research worthy.
Let’s dive into these interesting tidbits and clinical takeaways about neuro rehab.
From where do the rest of the vertebras get their spinal division when the cord ends at L1 & L2?
Around the L1-L2 vertebral level in young people, the spinal cord shrinks into the conus medullaris. The cauda equina that consists of lumbar, sacral, and coccygeal nerve roots which extend downwards to leave at their corresponding foramina, is located in the spinal canal underneath this. Because the vertebral column develops more quickly than the spinal cord during fetal development, spinal segments are higher than the corresponding vertebrae. The spinal formula, designed to help clinicians in assigning the appropriate spinal segments to vertebral injuries, provides a summary of this.
A section of spinal cord from which the spinal nerves emerge is called the spinal segment. According to the Spinal formula, the relationship between spinal segment & vertebral column can be given as:
- C1 to C7 + 1
- T1 to T6 + 2
- T7 to T9 + 3
- T10 lies over the L1 & L2 spinal segments
- T11 lies over the L3 & L4 spinal segments
- T12 lies over the L5 & upper sacral spinal segments
- First Lumbar Vertebra lies over lower sacral & coccyx segments
Clinical Takeaways
- The spinal levels and the vertebrae don’t align together. Hence it is important to know the formula for accurate diagnosis.
- In case of cauda equina lesions, the signs that appear are LMN along with asymmetrical weakness and radicular pain.
- Targeted rehab can be designed according to it.
Stroke is an UMNL & the characteristic feature of UMNL is spasticity. So why does the patient appear flaccid in early stages of stroke?
The brain’s descending excitatory input to spinal circuitry is dramatically eliminated right after a stroke. This results in a phase known as spinal shock or cerebral shock, which is characterized by temporary flaccid paralysis and hyporeflexia. This pathology consists of metabolic diaschisis and impairment of descending facilitation. The hypertonia and stiffness, that are the characteristic of UMNL, are caused by the gradual reorganization of reflex loops and the return of spinal interneurons to excitability.
Clinical Takeaways
- Early changes include Flaccidity, Hypotonia & Hyporeflexia
- Later on Spasticity, Hypertonia & Hyperreflexia
- The focus of early rehabilitation sessions should be on passive along with active assisted ROMs & sensory stimulation
What is the importance of Ascending and Descending Tracts?
Since the ascending and descending spinal tracts serve as the main channels of communication between the brain and body, an understanding of them is essential to neurorehabilitation. Sensory data like proprioception, touch, pain, and temperature are transported from the periphery to the brain via the ascending tracts, which include the dorsal column, spinothalamic, and spinocerebellar pathways. Coordinated motion is impractical without precise sensory data, which is why these sensations are essential for body consciousness, balance, and control of movement.
On the other hand, voluntarily performed movements and automatic postural changes are made possible by the descending tracts, which include the vestibulospinal, reticulospinal, and corticospinal tracts. These tracts carry motor instructions from the neural network to spinal motor neurons in the spine. The flow of information is disrupted when these tracts are damaged, as occurs in stroke, spinal cord injury, or traumatic brain injury. This can lead to aberrant movement patterns, weakness, spasticity, or lack of coordination. From the standpoint of rehabilitation, clinicians can better predict functional limitations, set achievable objectives, and choose the right treatments by understanding which tracts are impacted.
Clinical Takeaways
- Pathology of Dorsal Column tract suggests an amalgamate deprivation of vibration, proprioception and pain.
- A loss in pain, temperature on one side with weakness suggests the pathology of spinal cord hemisection.
- Impairments in precise distal function of the hand are predicted by disruption to the corticospinal system.
- Deficits of reticulospinal tracts give off loss of balance and tone.
How does acidosis lead to consciousness deprivation while alkalosis provokes seizures?
Acid-base imbalances affect not only neural excitability but also cerebral blood flow and synaptic outcomes. Acidosis, both respiratory & metabolic, slows down membrane excitability. Increased levels of carbon dioxide causes vasodilation & increased intracranial volume & when extreme acidosis comes into play, it disrupts the regulation of ionic channels & release of neurotransmitters leading to diminished neuronal firing rate progressing to coma.
On the other hand, alkalosis serves to raise membrane excitability because fewer hydrogen ions alter the balance of ion channel opening. Respiratory alkalosis also results in cerebral vasoconstriction, which can lower cerebral blood flow and result in symptoms like dizziness. However, when the neuronal excitability exceeds to a point more than the threshold it may lead to seizures in vulnerable patients.
Clinical Takeaways
- Patients with altered mental status following a stroke, brain injury, or in the ICU require prompt identification of ABG derangements; treating severe acidosis can save lives and raise consciousness.
- Individuals experiencing metabolic alkalosis or respiratory alkalosis such as during hyperventilation may be more susceptible to seizures; this is important when employing respiratory-centered procedures or when excessive ventilator adjustments cause anomalies in the ABGs. Prior to taking on difficult duties, rehab teams must work with healthcare professionals to maximize ABG status.
- In stroke patients, chronic acidosis might predict a worse result and necessitates immediate care; ABG abnormalities can reveal systemic issues that impede neurologic recovery.
Multiple Sclerosis is considered to be an example of synaptic delay. What actually happens during a synaptic delay?
The primary symptom of multiple sclerosis is central nervous system demyelinating illness. The protective myelin sheath in multiple sclerosis is disrupted or removed by localized immune-mediated demyelination. The consequences are:
- Reduced conduction velocity
- Intermittent failure or conduction block
- Sensitivity to temperature also known as Uhthoff Phenomenon
The delay is particularly noticeable in conditions like Multiple Sclerosis (MS) because demyelination hinders the action potential’s arrival at the synapse rather than at the synapse itself. Thus, weariness, incoordination, and tardy reaction are caused by a combination of synaptic delay and slowed conduction.
Clinical Takeaways
- Fluctuation in symptoms – MS patients may experience abrupt, temporary deterioration (accompanied by heat or weariness) because conduction becomes unpredictable as opposed to merely slow. This has an impact on therapy intensity and pace planning.
- Therapy targets – While therapeutic treatments seek to prevent additional demyelination and maintain axons, rehabilitation techniques focus on conserving energy, rhythm control, heat avoidance, and remedial training during conduction block. Unreliable conduction can be somewhat compensated for by physical therapies that enhance motor planning and recruitment.
Which muscles should be recruited first after a stroke?
The muscles that should be recruited depends on the area that is mostly causing the functional limitation & the muscles which can improvise the mobility better than others. These include:
- Dorsiflexors
The significance of dorsiflexors lies in the fact that it is needed for the clearance of foot during the swing phase of the gait cycle. Without operative dorsiflexion, patients may develop a hazardous condition known as foot drop that may lead to increased risk of fall. Training of the Dorsiflexors
- Quadriceps
The knee extensors are necessary for providing the stability of the knee during the stance phase & are also essential for the transfers such as sit to stand as well as maintaining an upright balanced posture whilst standing. Quadriceps Training
- Trunk Muscles
Postural corrections, seated balance, and limb movement coordination are all supported by trunk control. Adverse ADL results are highly correlated with trunk disability; improved functional mobility is predicted by an early recovery of trunk control. Trunk Training
Clinical Takeaways
- Although the recruitment of muscles is mostly dependent on the impairments of the patient, training these groups are essential because the earlier the dorsiflexors are trained the more stable base of support is established.
- Quadriceps training is necessary for improving the overall ambulation & performing the functional activities.
- Trunk control is the mother of all the basic functioning of the body. It is necessary for holding the posture, performing upper body and lower body coordinated actions as well as progressing to advanced levels of gait and mobility.
- Read more about Stroke in our blog 8 Essential Facts to know about Stroke Rehab
Why does strength training matter for the neuro patients when the strength is already present?
When it comes to neurological deficits, the fundamental deficiency occurs in the neural aspect that is reduced motor recruitment, atypical synergies and spontaneity. There are a number of distinct, scientifically supported advantages to neurorehabilitation training that go beyond hypertrophy. These include:
- Enhances the recruitment of voluntary motor units
- Intensifying force production and task-performance ability
- Increases endurance & capacity
- Supports motor learning & Neural plasticity
- Reduces risks of injury
- Increases neurotrophic units that aid in improved learning of patterns
Clinical Takeaways
- Isolated strength training when combined with task-specific activities can help promote transfers to ADLs.
- Carefully designed therapy programs can help reduce spasticity & co-contractions.
- Targeted training of the area helps the recovery to be more profound, accurate & quick.
- Hence, strength training is needed for better motor recruitment to improvise the overall functioning of the limbs.
Increased Base of Support increases stability but decreases mobility. How should this be incorporated in balance training?
The region enclosed by points of contact among the body and a sustaining surface, such as feet on the floor, is known as the base of support. When the center of gravity moves out of the base of support it results in fall. Therefore, the center of gravity is necessary to maintain stability. An increased base of support helps in increasing the overall stability as it reduces the risk of fall. However, it restricts the rapid weight shifts and performs the tasks that are required for functional activities.
During rehabilitation, the BOS is adjusted to promote the challenges of training:
- Patients with stroke or other neurological deficits begin with a wide base of support with many contact points to maintain stability.
- Gradually, the contact points are reduced along with the performance of tasks such as reaching, grasping and perturbations.
- Once the control & confidence is fully achieved, the midline cross can be incorporated as well during reaching activities to gain overall functioning capacity.
Clinical Takeaways
- The stable the BOS the more the focus is on the COG as both are necessary for gait and balance.
- The patient is exposed to progressive challenge of narrow BOS to improvise the overall function.
- By activating the vestibular and proprioceptive systems, BOS manipulation improves neuroplastic balance recovery.
- A crucial element of mobility retraining, weight transfer ability, is enhanced by adjusting BOS.
The Power of Understanding the Interesting Tidbits about Neuro Rehab
The fundamental physiological and anatomical concepts that underpin neurorehabilitation include spinal cord levels, neural tracts, synaptic delay, tone variations, and the base of support. These ideas may appear simple, yet they provide the rationale for each treatment choice we take. It is crucial that all therapists fully comprehend and consider these principles before starting any therapeutic plan. Clinicians can more accurately, confidently, and creatively plan treatment when they understand why flaccidity unfolds after strokes, how conduction delays impact recuperation, or the consequences of change in base of support.
These are the mechanisms that influence motor control, balance, and neuroplasticity in actual patients; they are not merely information from textbooks. In the end, these clinical takeaways are instruments for professional development and lifetime learning, not for temporary memory. We can assist our patients in relearning, recovering, and regaining their independence more successfully if we have a deeper understanding of the science underlying movement.
This article has been written by a Physical Therapist and provides general guidance on physical health & exercise. While it is grounded in professional expertise, it is not a substitute for individualized medical advice. If you are experiencing pain, specific symptoms, or have an underlying medical condition, please book a 1 on 1, 30 minute consultation with our expert physical therapist for a personalized assessment & tailored recommendations.