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