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The appropriate moment for
neuro-rehabilitation after
neurological/neurosurgical
impairment in elderly
Authors: Daniela Profir, Viorica Marin,Sibel Demirgian, Olga
Surdu, Elena
Valentina Ionescu, Liliana Elena
Stanciu
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In terms of medical research, modern medicine
means interfering with cellular infrastructure andwith intimacy
of biochemical processes,peeling the nucleus and decoding the
geneticcode.
Adding the avalanche of modifying diseasedrugs and the
technological progress inorthotics and prosthetics, its
understandable
why its so difficult for the neurologist orneurosurgeon to
establish a therapeutic planwhich includes the right place for
balnealrehabilitation.
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Balneal and physical therapy is acting ondisease phenomenon not
simply in causalsense, whereas between the therapeutic meanand
pathologic process is standing the affectedbody as a whole, with
its own multiple regulation
systems and reactivity.
Activation of these complex systems by thenatural factors is
influencing cause-effect
correlation, which establishes between thetherapeutic agent and
the affectedorgan/function.
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The difficulty in assessing therapeutic effects is
given by the fact that balneal therapy is atherapeutic complex,
which includes, besideknown factors (mineral waters, mud), changeof
climate, habitat, diet, lack or diminishing ofdaily stress. All
these factors influencedifferently the final result of the
treatment.
Complex adapt ive responses of the body
funct ion s to sys temat ic, sequent ia l, dosedapp l icat ion
of some stress ing factors
(thermal, chem ical, mechanical) on sk in o r
mucosa represent adaptat ion therapy .
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The methods of balneal therapy are mostlytraditional methods,
based on a long timeobservation and having specificity for
eachresource: climate, mineral waters, different typesof mud,
therapeutic gases. Though, the group of
methods used in spas rehabilitationdepartments belongs to
physical medicine:
- electrotherapy
- photobiology and therapy
- hydro-thermo-biology and therapy- kinesiology and massage
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In balneal resorts these groups of methods are
individualized because the therapeutic vectorhas a natural
origin. It can be added thepresence of bioclimatic elements: sun
lighteninggradient, humidity, atmospheric pressure,
partialpressures of gases, the presence of aerosols
and/or ions, radioactivity, etc.
The rehabilitation cure is placed in time
afterhospital/ambulatory moment, where are solved
diagnosis problems or emergency intervention.The patient must
arrive in balneal resortdiagnosed and with stabilized vital
functions.
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Choice of the adequate moment and place forthe patient with
neurological /neurosurgical
impairment it depends of understanding the
adaptive capacity of the patient and the
potential offered by natural therapeutic factors.
Thats why timing for rehabilitation cure and
selection of proper balneal resort are sine qua
non conditions of an efficient rehabilitation
treatment.
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During neuro-rehabilitation the nervous system mustensure:
- maintaining of its own structural and functionalintegrity, at
least the rest of it;
- regulation of the information flow from peripheralreceptors to
control systems, in case that some (or all) ofthem are affected:
information receiving, transmissionpathways, control
modalities;
- fast and appropriate functional response to thechanges of
environment;
- rapid and specific coordination and integration of theother
organs and systems activity with change ofambient conditions;
- informational, structural and energetic substrate ofcomplex
functions: thinking, intelligence, memory.
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Requirements mentioned above outline reactiveparticularities of
the patient with neurological or
neurosurgical impairment. Especially neurologicaldisease is
modifying relationship that patient establisheswith himself and
with the environment.
Changing the environment and transforming it into a
therapeutic factor, as it happens during balneal process,has
significant psycho-affective, biological,
physiological,physio-pathological implication upon the affected
body.
The main target of the complex process ofneuro-rehabilitation is
the main affected structure itself, sothat the results depend on
the correct evaluation ofbiological adaptation capacity and of the
right choice ofthe moment and place for therapy.
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The indication for rehabilitation cure must bedone after the
physician has properly analyzedthe impact of each factor upon the
patientsbody.
The same way of thinking must be followed by
the balneal therapist, who is prescribing andfollowing up the
treatment.
The natural therapeutic factors are:
- climate- mineral waters
- various types of mud
- therapeutic gases
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ClimateClimate represents all physical (cosmic, atmospheric,
terrestrial) and biological factors, that characterize anarea
and act together upon humans.
The climatic elements which are influencing the bodyresponse
are: temperature, humidity, air movements,
sun radiation.
Small variation of these factors is neutral or sedative forthe
organism, being compatible with impaired functionalstatus of
neurological/neurosurgical patient and with
therapeutic aims of rehabilitation. Beyond the tolerancelimits
of the patient, the factors become stimulating; overthreshold
values they are becoming stressful and thuscontraindicated for the
cure.
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The relationship between the organism and climate is
shown by two indices: thermal comfort index and
bioclimatic stress.
Thermal com fort indexis referring to a complex
relat ionshipbetween temperature, humidity, and wind
on one side, and thermal sensation perceived by theorganism on
the other side.
Bioc l imat ic stressoutlines oscillation limits of main
meteorological elements; inside these limits human bodyis
maintaining a balance of principal regulation systems,
and beyond these limits are trained homeostatic
adaptation mechanisms.
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Depending on the solicitation of constitutive climaticelements
upon the body, there are three types of
climate:- sparing climate, found around hills and plain
areas,foothills and forestry, requires not too much from
theadaptive systems; these areas are best choice for
neuro-rehabilitation
- exciting climate, found over 1000 m high and aroundprairies,
requires much more body adaptability and itsnot recommended for
neurological impairment
- tonic stimulating climate, has mixed elements,depending on the
season. It can be found on the BlackSea side, where in autumn and
spring patients can gofor balneal cure.
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Its necessary considering the impact of climate
upon the organism, especially for the firstrehabilitation cure,
in patients with severe neuraltraumas, complex traumas with
neural-vegetative impairment, cerebral-vascular
diseases and central degenerative diseases.
Special attention must be paid to acuteperturbation of
consciousness status (epilepsy),
which can be associated with above mentionedpathology; sometimes
first crisis can appear inthe spa resort, as a result of
accommodation tothe climatic stress.
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Mineral waters
Mineral watersare natural solutions of salts, ionicdissociated
or not, in balance at the source. Theconditions of a declared
mineral water are:- to contain al least 1g salts/l;
- to contain solid or gaseous chemical elements withtherapeutic
action scientifically proved;
- the temperature of the source must be minimum 20C;- to contain
microelements.
There are many criteria used for classification of mineralwaters
as: concentration of salts, temperature, chemicalcomposition.
Therapeutic lakes are waters with variousmineralization, which
can be used for swimming,
forprophylactic/therapeutic/rehabilitation aim.
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Muds
Muds are natural plastic aggregations, rocks of
pastyconsistence, used as therapeutic remedies. Theyformed either
by means of underwater depositing oforganic or inorganic material
(curative sediments) orby dissolution of some rocks under the
action ofatmospheric agents (therapeutic soils).
In Romania there are three types of mud :- saprogenic muds,
which are sulfuric, oily deposits,
formed on the bottom of seashore lakes (Techirghiol),or plain
lakes, out of former seas (Amara).
- peat, which are vegetal organic, brownie
deposits(Poiana-Stampei, Mangalia the only marine peat,Stobor the
only vitriolic peat).
- mineral muds, which are forming by sedimentationof some salts
from carbonated, calcic, ferruginous,
sulfuric sources.
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External cure with mineral waters and mud
Thermal field of hydro-thermo-biology extends from cold
applications to hyperthermia, every type of applicationhaving
characteristic indications, effects and therapeutic
consequences.
Temperature of water (therapeutic bath) to which
thermoregulation mechanisms are minimum solicited iscalled
thermal neutrality.
There are different types of bath, depending of
temperature:
- cold baths in lakes or sea, associated with cold
mudointment
- neutral warm baths, most frequently used in neuro-
rehabilitation
- hyperthermic baths
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During neutral warm bath the organism undergo
forces corresponding to physical laws ofArchimedes and Pascal.
Due to the pressure
inside the water body weight decreases and
movements can be performed easier. Besides,
there is also a relaxing effect on the striatemuscles.
Concomitantly with the significant decrease of
gravitational and thermal information, there is an
increase of information from the inner receptors(baroreceptors)
Bainbridge effect, it triggers
Henry-Gauer reflex and the blood pressure
lowers with 30% after 30-40 minutes.
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The factors that matters in making up a correcttherapeutic
choice are:
Age
General functional status of the organism
Neuro-mio-arthro-kinetic and others systems
and organs functional residualEducation level and compliance of
the patient
Sometimes, patients can be very demanding
about the number of procedures per day or themaximal parameters,
but the balneal therapisthas to manage the situation with ability
andpatience.
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Techirghiol Lake is a salted lake situated in thesoutheastearn
part of Romania, famous for itstherapeutical effects due to the
natural depositsof saprogenic mud.
In Balneal and Rehabilitation Sanatorium ofTechirghiol we are
treating patients withneurological/neurosurgical impairment
usingmud and salted water from the lake.
There are two different ways of mud application:- cold mud
ointment, followed by immersion in
the salted water of the lake and sun exposure
- warm mud bath or packing
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The treatment applied to patients with neurological
/neurosurgical impairment consists in:- daily application of
hydro-kineto-therapy;
- kinesiology sec in the gym room on a daily basis;
- daily massage session;
- 2-4 procedures of electrotherapy per day.
Hydro-kineto-therapy is applied in the therapeuticswimming pool
with salted water, heated at 35C (neutralthermic), where patients
perform exercises guided and
helped by qualified stuff. Programs are individualized bymedical
prescription, but there are also working groupsfor the patients
whos neurological damage is lesssevere and need no help.
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For patients with neurological severe disabilitieswe are using
bathtubs with special forms(butterfly). For patients with less
severesequelae and associated cardiac, vasculardiseases we are
using simple bathtubs. Mudapplication is done frequently as general
neutral
warm baths. Salted or herbal baths areprescribed alternatively
with warm mud baths.
Kinesiology performed in the gym room isapplied individually or
in groups of 2-6 patients
with similar diseases, supervised and helped bythe physical
therapist. Working in small groupsawakens competition spirit among
patients,sometimes stimulates imitation.
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Before the kinetic program in the gym room, the
patients undergo a thermal procedure, in orderto prepare the
muscles. In cases where this is
not possible, the doctor prescribes electric
procedures (short wave diathermia or
ultrasound).
We are using various types of electric impulses
in order to reach muscular and vascular
stimulation or analgesic effect.The daily program ends with a
massage
session, which is very relaxing for the patient.
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Contraindications
Correct establishment of contraindications for
neuro-rehabilitation cure is the most important condition in
order to get good therapeutic results.
Its very difficult to transport a patient with recent, not
stable, neurological/neurosurgical impairment and
otherassociated pathology, all the way to the spa resort.
Until few years ago, sphincter control alteration was an
impediment for sending the patient to balneal therapy.
Actually, because of condoms with adhesive and
lubricated tubes, these patients can get treatment
without feeling any discomfort.
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The most important contraindications for balneal
rehabilitation are:
Patients with acute and/or inflammatory stage of
disease, or incompletely diagnosed.
Patients with trophic skin lesions
Patients with neurological affection due to an infectiouscause
(in contagious stage)
Patients with associated malignant tumors, generating
locomotor deficits
Patients with associated diseases: cardio-vascular,hepatic,
renal, respiratory not compensated
Patients with major psychiatric diseases, with comitial
crisis not controlled by medication.
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Conclusions
Thats why the indications list will be very short:
the patients with neurological/neurosurgical
impairment, except those in one of thementioned situations, can
benefit from the
effects of natural factors, correctly applied as
neuro-rehabilitation cure.
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Thank you for your attention!S
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