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| INVITED LECTURE SUMMARIES |
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| Year : 2021 | Volume
: 15
| Issue : 3 | Page : 129-135 |
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Invited Lecture Summaries
| Date of Web Publication | 16-Mar-2022 |
Correspondence Address:
 Source of Support: None, Conflict of Interest: None  | Check |
How to cite this article:
. Invited Lecture Summaries. Physiother - J Indian Assoc Physiother 2021;15, Suppl S1:129-35 |
| Title what can we learn from the dysphagia of Wallenberg syndrome: Disruption of the obligatory swallowing sequence, factors affect the severity, and effective rehabilitation? | |  |
Mari Nakao
Physiatrist, Japan
Invited guest lecture: 7th August 12:00 – 12:30 IST
Dysphagia is disorder with swallowing. In Europe 30-40% in independent older people, in United States 6-10 millions people, and in Japan more than one million people is estimated to suffer with dysphagia. To find out the clue for the treatment of dysphagia, understanding swallowing physiology is important.
Wallenberg syndrome is a specific series of symptoms including dysphagia caused by lateral medullary infarction. To understand swallowing physiology, role of medulla and it's disorder supply important information because central pattern generator (CPG) for swallowing, which produce rhythmic motor pattern of swallowing movement, is situated.
We studied and published in 2019 about the differences in swallowing dynamics between 35 patients with Wallenberg syndrome and normal subjects on the previously published articles. In this study, we found that the majority of the patients with Wallenberg syndrome had a reversal of the swallowing dynamic sequence that always occurs in normal subjects (obligatory sequence). In this lecture, we will report on this study in detail.
In addition, subsequent studies have shown that the severity of dysphagia in Wallenberg syndrome is related to the vertical extent of the lesion rather than the horizontal extent of the lesion on the MRI.
We present a rehabilitation program that is indicated for the dysphagia of Wallenberg syndrome. In Wallenberg syndrome, the inability to open the upper esophageal sphincter (UES) on the iected side (sometimes bilaterally) has been the focus of much attention, and rehabilitation has been applied clinically to address this problem. For example, the head lifting exercise, also known as the Shaker exercise, is known to strengthen the muscles that tract UES on the opening, such as the Geniohyoid muscle. In addition, balloon dilatation exercise of the UES is also a clinically used technique. Postural adjustment (reclining method) to control the flow of bolus by gravity, head rotation to open the UES on the uniected side is also clinically performed.
If we focus on the sequential disorder of Wallenberg syndrome, other rehabilitation options may be considered in addition to these. Here, we report our training experience. We have studied six cases of brain stem stroke (five cases of lateral medulla, one case of pons). We performed exercise-based rehabilitation in six cases of brain stem stroke patients (five cases of lateral medulla, one case of pons) for three weeks. The program was the McNeil Dysphagia Therapy Program (MDTP) developed by Carnaby-Mann and Crary. All patients started training with a Functional Oral Intake Scale (FOIS) Lv. 5 and improved to a FOIS Lv. 7 within 3 weeks. This result suggests that motor learning through repeated swallowing exercises can improve sequential disorder. A detailed analysis of this study will be presented at the World Dysphagia Summit @ Nagoya, Japan on August 19-33.
Under the pandemic of COVID-19, rehabilitation for our dysphagia patients is faced with many challenges. To successfully treat these patients, it is essential to go back to the basics and choose a rehabilitation program that is based on the physiology of swallowing.
In addition, to provide care sustainably with limited medical resources, it is necessary to consider how to discharge patients from the hospital to the community or home safely. Good cooperation and information sharing between community professionals and hospital professionals are required now more than ever. We have created a tool called the “Niigata dysphagia management diary” to share information between community care workers, families, patients themselves, and their physicians. This tool can be used as an example of multidisciplinary team approach not only in hospitals but also in the whole community to realize “Holistic rehabilitation from hospital to home”. We hope that you will find this tool useful.
| Autism and Aquatics | | |
Meredith Morig
Pediatric Occupational Therapist & Clinical Instructor, PremaPlay, Sanford, USA
Autism Spectrum Disorder is a developmental disability that can cause significant social, communication and behavioral challenges. The learning, thinking and problem solving abilities of people with autism can range from gifted to severely challenged. In addition, many people with autism demonstrate difficulty processing sensory stimuli, have trouble understating other people's feelings or talking about their own feelings, appear to be unaware when people talk to them, repeat or echo words or phrases to them and have trouble expressing their needs using typical words or motions. The water provides 30 times more proprioceptive input than land, giving people with autism, constant deep pressure and input throughout the entire body. This can organize a person's sensory system, improve attention and processing and ultimately improve body awareness. With increased body awareness, skills requiring coordination will improve. The water challenges a person's ability to multi task by requiring use of bilateral coordination, trunk strength and visual spatial awareness simultaneously. In addition, the water is very motivating and provides many opportunities for functional communication. Although communication for people with autism can appear challenging, it is important for them to feel heard and understood, even if it means communicating a little differently. There are many ways that communication, activities and exercises can be adapted to benefit from the properties of water and ultimately improve functional skills. When working with people with autism, it is important to embrace any differences and support them. The water provides us the perfect environment to do just that.
| Music therapy in neurorehabilitation | | |
Michael Thaut
Professor of Music at the University of Toronto with cross-appointments in Rehabilitation Science and Neuroscience, Director of the University's Music and Health Science Research Center (MAHRC)
A summary of new data in clinical music neuroscience research and translations to Neurologic Music Therapy.
| Aqua Therapy | | |
| Paediatric aquatic therapy, application in early intervention | | |
Mona Patel
Paediatric Physiotherapist, & Paediatric Aquatic Therapist, SPARSH Paediatric Rehabilitation Clinic
Summary: I will be discussing why early intervention is important and how aquatic therapy helps in early intervention and will be supporting it with my case studies and references from research. Why early intervention is important: As Karen Pape [Neonatologist] explains in her book, Baby brain if suffers damage has 2 task at hand 1) To grow 2) To recover from damage Baby brain gets double in weight by 6 months and 75% by 2 years and 90% by 4 years So it is very important to start early as synaptogenesis hits its peak at 2-3yrs of age so we have to start treating early so that we can: 1) Maximize neuroplasticity 2) Minimize maladaptive habits HOW DO WE DO IT By providing stimulation through enriched environment. Water has a very rich sensory motor environment. How Aquatic therapy has an edge as a therapeutic tool for Early intervention for kids with neuro motor challenges: 1]Better self-regulation and better sleep 2]Better Participation 3]Better postural control (anticipatory and reactive control) 4]Pain free elongation of spastic and tight muscles 5]Helps reduce hyperreflexia and hypertonicity[spastics] 6]Better core activation (both inner and outer core) 7]Better medium for easy and efficient fascial release 8]Better sensory feedback both somatosensory and vestibular[For Hypotonics as well as for Kids with ASD and ADHD] 8]Helps to reduce involuntary movements (dystonia and athetosis) 9]Helps to improve balance as gives patient more time for problem solving and Balance restoration. Less risk of falling 10]Lots of opportunities for rotations which further helps reduce spasticity 11]Lots of opportunities for dissociation and selective muscle facilitation 12]Advantage of changing environmental context (land and water) as a result skill that develops can be easily generalized which in turn helps facilitating motor problem solving ability 13]Easy and quick changes between varied range of functional training options 14]Better speed and endurance 15]Reaction time reduces and performance in sequential motor task improves 16]Brain plasticity - physical exercise with some kind of quality/intensity and environmental enrichment 17]Environment Enrichment- enhanced Sensory, motor, cognitive and social stimulation, easily possible with water 18] Infant seek lot of sensory motor stimulation, water provides ideal environment 19]Evidences on immersion causing increase in attention and memory as well as improvement in executive function 20] Better brain blood flow We use Water specific therapy as primary tool for treating our infants and toddlers in pool but also as part of my diversified practice, I combined principles of lot of approaches like Total motion Release toddler and teens [TMRTOTs], Neuro Development Treatment[NDT] as well as using different approaching primarily focusing on facilitating postural control and motor control along with Water Specific Therapy in My Aquatic Practice. I will be presenting 3 case studies where how we made significant changes with combined use of aquatic and land based therapies: 1] 2 month old Spastic Dystonic Cerebral Palsy[PVL-grade 4] We worked on him through tele rehab where Mother worked with him in pool almost 4 to5 days a week in small pool and we made significant changes in terms of helping him come out of severe extension and move his body and extremities freely as well as better Head control, achieved rolling and ability to sit with support in a period of 5 months. 2]A child with multiple issues and Global development Delay, how he achieved all his milestones from head control to independent walking in period of one and half year[starting when he was 3 month old till 2 years] 3]A 3 year old with Lt Hemiparesis – I will be sharing gains we achieved at all the levels of ICF. Research References for Aquatic therapy in Early Intervention: 1] The effect of aquatic therapy on functional mobility of infants and toddlers in early intervention [Beth M McManus, Milton Kotelchuck] 2] Effect of aquatic physical therapy on pain and state of sleep and wakefulness among stable preterm newborns in neonatal intensive care units[Carine Moraes Vignochi 1, Patrícia P Teixeira, Silvana S Nader] 3] Aquatic therapy for a child with type III spinal muscular atrophy: a case report [Yasser Salem 1, Stacy Jiee Gropack].
| Symposium on Movement Disorder | | |
| Post stroke movement disorders and management | | |
Muhammad Umar
Orthotist & Prosthetist, Pakistan
Post stroke movement disorders could be many and have different time frame for their development. The lecture will highlight both the hypokinetic and hyperkinetic post stroke movement disorders and their management.
| Experience of COVID 19 and Neurorehabilitation Symposium | | |
| View Point from Pakistan | | |
Muhammad Naveed Babur
Physiotherapist, Pakistan
Severe acute respiratory syndrome coronavirus 2 or more commonly known as COVID 19 has caused devastation throughout the world since its first discovery in December 2019. Since then this historical pandemic has spread across globe wreaking havoc and effecting all countries alike. The World Health Organization (WHO) has classified the coronavirus epidemic as a global public health emergency of international concern. Like other countries Pakistan has also been severely iected by this pandemic and since report of first in late February 2020 the cases have been continuously on the rise. Following this there was a significant surge in positivity due to influx of infected pilgrims from Iran. In addition to this only within in 15 days of report of first case the cases plummeted to 202 infected patients. Such situation was expected considering the low literacy rate, general lack of awareness regarding COVID leading to non-serious behavior of people towards the adoption of social distancing, hand hygiene and other COVID SOPs. Like other lower middle income countries Pakistan is has scarce hi end medical facilities and have inadequate health strategies. This along with high population density in major cities with public having unresponsive attitude of towards general protective measures contributed to increase in number of cases. Since Feb 2020 Pakistan is continuously struggling to flatten the curve but has seen 3 Waves of COVID 19 and is now preparing for delta wave. The Govt has been trying its best to tackle this challenge considering all ways of life to prevent any major setback with major focus on healthcare provision. The country minister and Chair of National command and operation center managing all COVID related issues said “The target is to prevent healthcare system from getting choked besides reducing hunger, poverty, unemployment due to COVID-19”. For said purposes number of steps have been taken including complete lockdown on march 23rd 2020 including closure of all educational institutes, recreational centers, wedding halls etc., However, the struggling economy of the country forced the government to lift the lockdown on May 9, 2020. As COVID significantly impacted countries economy as evident from the fact that National Poverty rate increased by 33 Percentage points during the Lockdown and closure of different sectors resulted in drop in GDP and loss of Rs. 1.3 trillion to counties economy, the counties focus shifted from complete lockdown to selective smart lockdowns of hot spots with relation to infection rate. Current stats show that since Feb 2020 Pakistan has seen over 1.03 Million Confirmed cases of COVID 19 with currently having over 70 thousand active cases. Majority of cases being reported are from Sindh and Punjab, two provinces with major population chunk. COVID-19 posed unprecedented challenges to states and communities across the globe. Like in many other countries, the health sector in Pakistan has Putin massive efforts to control the spread of this pandemic in Pakistan and to care of the ill presenting in any health setting. The pandemic has put healthcare professionals working in ERs, ICUs, Laboratories, and other departments in an unprecedented situation, with difficult decision options and intense pressure for maneuvers. This significantly impacted the healthcare system resulting in. • Hindrance to elective healthcare services • Limited patients' access to accident and emergency departments • Changes in patient administration systems such as shift to telephone consultations instead of face to face consultations resulting in Surge towards the use of telemedicine • Increased need for multidisciplinary team collaboration to manage covid patients • Need for increased heath care capacity including increase in intensive care units beds, sti and supplies such as PPEs, Masks, Ventilators etc) • Special emphasis being put on Physical and psychological pressures in health care workers in Pakistan due high risk of infection, inadequate equipment for safety from contagion, isolation, exhaustion, and lack of contact with family Similar to all aspect of Health care Rehabilitation care especially Neuro Rehabilitation has also been impacted due to COVID 19. COVID 19 has increased the need for rehabilitation services in Intensive care rehab and for patient with post COVID long term complications. For such purpose in country like Pakistan where health facilities had limited capacity, special measures were taken for conversion of different departmental wards into COVID isolation units, High dependency units and ICUs to have more beds for COVID patient to cater for increasing patient inflow. In addition to this to ensure the care of patients iected by other medical conditions whose admission cannot be postponed numerous Inpatient beds of Neurological rehabilitation were converted to COVID beds and inpatient Neuro rehabilitation services were halted. This resulted in disruption of care for Non COVID Patients requiring continuous support and care such as, Stroke patients, SCI patient, Children with Cerebral palsy and elderly etc., for some time but was somewhat catered for by provision of tele rehab services, home health services and outpatient services. Similar to this at some places specialized Rehabilitation Hospitals were also converted to COVID hospital and isolation Centers. This is evident from the fact that the country's largest dedicated tertiary care Physical rehabilitation hospital with more than 100 bed facility providing a range of comprehensive and multidisciplinary services to people with disabilities was converted to 130 bedded quarantine and Isolation facility. Limited services in some facilities and closure of other neuro rehabilitation facilities resulted in overwhelming patient presence and intake in other neuro rehabilitation centers of the regions. This resulting in increased demand of admission in neuro rehabilitation services having limited work personal eventually exhausting resources including human resources. While some facilities were completely shut down access to others was difficult. To curb the increasing number of cases the govt instituted suspension of all trains and inter district Passenger transit including urban passenger transit. This was in addition to imposition of ban on movement of elderly, children and people with health issue. Considering the fact that almost 70% of counties population live in peripheries the individuals with specialized neuro rehabilitation needs were unable to access care. Due to difficult of in some cases complete lack to any transportation. Similar to people, neuro rehabilitation professional also faced difficulty accessing patient receiving care in home based setting. Considering the restrictions imposed by the healthcare authorities in the movement of people to prevent the spreading of the infection. This situation had a significant negative impact in the short term, mainly for those patients at higher risk of deterioration of their functional abilities due to lack of rehabilitation care. In addition to this Physical distancing and isolation measures implied the suspension of physiotherapy services, which impacted negatively on patient's quality of life and health and impaired physiotherapists ability to manage the continuum of care for patients with chronic neurological conditions such as Stroke, SCI, Parkinson's etc., COVID 19 also resulted in reappropriation of not only physical resources but also human resources from specialized neuro rehabilitation units to intensive care units to care for COVID 19 patients. This predominantly due to significant patient intake of COVID but also due to non-availability of sti as a result of COVID infection or isolation. In addition to this manpower from orthotics and prosthesis sector was also shifted from developing orthotics and prosthesis to development and production of Masks and PPEs to cater for the limited supply and increased demand of masks and PPEs. This resulted in significant delays in development of Orthosis and prosthesis from neuro rehabilitation patient requiring some form of support orthotics etc., Physical and mental health of the work sti and health professionals was also one of the issues faced during the recent COVID 19 pandemic. Long working hours with increased physical work demand resulted in health professional with significant physical and mental exhaustion and fatigue. Mental health was further challenges in by additional emotional challenge due to managing COVID patient not having contact with family members due to risk of virus transmission, fear of infection and transmission. This emotional stress was in addition to stress resulting from witnessing deaths of COVID patients and forced self-isolation and monitoring at home as a result of suspected infection. All these highlighted the need for mental health care for rehab and health professionals. While significant challenges were identified some opportunities also raised in wake of COVID. The country lack significant barriers to tele medicine and rehabilitation with lack of infrastruction, internet access, awareness. COVID 19 promoted the incorporation of telerehabilitation services to tackle the issues of limited access arising suspension or delay in outpatient services, ceased home based rehabilitation services, lack of access to health care facility. In addition to this having better telehealth services in 3rd world countries; International hospitals offered aid inform of free online multidisciplinary rehabilitation programs, consultation and online health scans and tailored treatment regimes for patients in Pakistan, COVID also provided opportunity for health professional to Up skilling rehab care services provided to patients under infectious control protocols for such professionals were provided trainings related to barrier protocols and effective and judicious use of PPE and provision of rehab care to COVID patients. All in all COVID 19 is far from over in Pakistan and future policies and reforms can be carried out considering all aspects of neurological rehabilitation care and current situation of COVID 19.
Acknowledgement: Dr Muhammad Ehab Chaudhry, PhD scholar for acquisition of data.
| Aqua Therapy: Case Discussion | | |
| Application of aquatic therapy in a young adult with spinal cord injury | | |
Nidhi Agarwal, Anjali Shetty
Department of Neurological Rehabilitation Aquacentric Therapy, Mumbai, Maharashtra, India
Every year 250000-500000 people suffer from spinal cord injury (SCI) globally. Majority of these cases are seen in young adults between 18-35 years due to preventable causes such as road triic accident, falls, and violence. In India, most common cause is fall from height. SCI resulting in paralysis has devastating physical, mental, social, economic, sexual and vocational consequence for the youths with SCI. Many studies have shown benefits of aqua therapy to enhance aerobic capacity, improve strength, endurance, improve range of motion, reduce pain and enhance sense of mobility and independence in water in SCI. People with SCI lead sedentary lifestyles, experiencing poor quality of life and medical challenges. Aqua therapy as an adjunct to land therapy may alleviate boredom and enhance compliance. This case study discusses the assessment and management with aquatic therapy of a 28 year old with spinal cord injury (T9-T10) classified as grade A on ASIA scale, complete injury. Her Chief complains are: Difficulty to sit independently without support Difficulty with bed mobility and dependence on all ADLS of self-care and transfers. Early fatigue with upper limb activities Difficulty in walking Based on her assessment, major impairments that were identified are as follows: Poor sustenance and co activation of abdominal and back extensor muscles. Autonomic dysfunction Motor and sensory loss below T10 level Tightness of pectoral muscles Reduced ROM OF left shoulder. Immature weight bearing and weight shifts in sitting and standing Difficulty in activation and initiation of lower limb muscles Based on assessment and client expectation following goals were set: She should be able to sit independently for 1 hour without support on wheel chair with appropriate neck and trunk alignment Client should be able to independently turn from supine to side lying She should be able to come from side to sitting and transfer with minimal assistance Client should be able to walk 10m with walker and calipers independently. Her rehabilitation spanned over 5 months with aquatic therapy frequency of 3 times/week. Duration of each session was 45 mins. SCIM -III, WISCI-II and FRT were taken at baseline. Aquatic intervention were carried out in an indoor temperature controlled pool. Therapeutic aquatic strategies that were used are Bad –Ragaz Ring method, Water specific Therapy to improve trunk control and alignment. Other activities like upper limb strengthening with equipment's, functional activities like sit to stand and walking in water using underwater treadmill were incorporated. Results obtained at the end of 100 sessions showed changes in the following outcome measure. At baseline SCIM-III was 24/100 and post therapy was 65/100, there is also improvement in WISCI-II which at baseline was level 0 and post intervention was level 6. There is improvement in Functional reach test which at baseline was 14 cm and post therapy was 35cm These changes indicated there has been improvement trunk control, inter limb dissociation for walking, improved weight bearing and weight shifts in sitting and standing, improved upper limb strength, improved body alignment and reduced energy expenditure. Thus, in conclusion aquatic therapy is shown to be a useful tool in rehabilitation of spinal cord injury. The strategies suggested may be effective adjuncts to conventional land based neurorehabilitation techniques popularly used in management of SCI.
| AOCNR 2021 Symposium: Neuromuscular Disorder | | |
| Up-close with Guillain–Barré syndrome: Variants, mimics and chameleons in the neurorehabilitation setting | | |
Norhayati Hussein
Physiatrist, Malaysia
Guillain–Barré syndrome (GBS) is an inflammatory disease of the peripheral nervous system and is the leading global cause of acute flaccid paralysis. The prevalence of GBS is estimated to be 1–3 per 100,000 worldwide, and the disease is more common in males than in females. The GBS incidence increases with age, although all age groups can be iected.
The diagnosis of Guillain–Barré syndrome is largely based on clinical features and supported by serological, electrodiagnostic, and immunological investigations. Key features are weakness, hyporeflexia/areflexia and raised CSF protein concentrations without pleocytosis.
Patients with GBS classically presents with features of symmetrical sensori-motor signs in the lower extremities which gradually ascends to upper extremities and may involve the cranial nerves. Although this symmetrical paralysis of the extremities forms the classic presentation, the clinical presentation of the disease is heterogeneous, and several distinct clinical variants exist. There are several presentations of GBS variants depending on topographical involvement. The GBS variants include classic sensorimotor, pure motor, paraparetic, pharyngeal-cervical-brachial (PCB), bilateral facial palsy with paraesthesias, pure sensory, Miller-Fisher Syndrome (MFS) and Bickersti brainstem encephalitis. These variants may be distinct; yet often overlap and forms a continuous spectrum of discrete and overlapping syndromes. The differential diagnoses (mimics) for GBS can be broadly divided into those presenting with symmetrical extremities weakness and those presenting with brainstem signs. Miller-Fisher Syndrome (MFS) and the pharyngeal-cervical-brachial (PCB) variant of GBS are frequently mistaken for brainstem stroke, botulism or myasthenia gravis. Bickersti's brainstem encephalitis may be mistakenly diagnosed as Wernicke's encephalopathy and other encephalitis-related disorders.
Atypical presentations (chameleons) of GBS-related disorders include paraparetic GBS, bifacial weakness with paraesthesias, acute ataxic neuropathy, acute ophthalmoparesis, acute ptosis and acute mydriasis. Though GBS iects the peripheral nervous system, clinicians may be unaware that deep tendon reflexes remain present and may even appear brisk in up to 10% of patients with GBS.
This lecture will review the spectrum of GBS variants, the important differential diagnoses (mimics) for patients presenting with acute flaccid paralysis and brain stem signs; and highlights the atypical presentation (chameleons) of GBS-related disorders which may be encountered in the neurorehabilitation setting. A good appreciation of GBS variants and the common GBS mimics and chameleons is necessary for the accurate diagnosis and treatment of GBS. This will assist in realistic recovery prognostication and enable accurate planning of neurorehabilitation management.
| Experience of COVID-19 and Neurorehabilitation Symposium | | |
| View point from Malaysia | | |
Norhayati Hussein
Physiatrist, Malaysia
Malaysia is experiencing the ongoing fourth wave of COVID-19 pandemic, which crucially impact the overall nationwide health-care services. This viewpoint is based on the experience in the context of COVID-19 pandemic - with special reference to a neurorehabilitation setting within a free-standing rehabilitation hospital in Malaysia. This is complemented by collective experience gleaned from other rehabilitation services nationwide.
Due to the current pandemic, neurorehabilitation services in Malaysia are iected and require aggressive adaptations; both in the overall organization and in the operational process and methods to maintain safety of patients and clinical personnel in a seamless manner. The monumental challenge relates to finding the balance between provision of timely and effective neurorehabilitation services despite resources limitations; and minimizing the risk of spreading COVID-19.
Nationwide health-care facilities especially inpatient wards were repurposed to treat COVID-19 patients. The COVID-19 hybrid hospital status iects timely access to inpatient neurorehabilitation. Outpatient neurorehabilitation services were redesigned to ensure early access to collaborative interdisciplinary neurorehabilitation care via Integrated Neurorehabilitation Clinic Consultation. Specific inpatient service routines were omitted to ensure reduction of infection risk. Neurorehabilitation routines and practices incorporating the 'Environmental Enrichment' concept; so crucial for neurological patients were inadvertently restricted, in addition to imposing restrictions in communal activities and visitations. Tele-neurorehabilitation was swiftly adopted to enable virtual clinic consultations and monitoring, speech therapy & audiological intervention, neuropsychological assessment & treatment and promoting therapeutic exercises. Interdisciplinary conferences and educational training sessions were conducted via online platforms. To date, it has been a period of continual improvements, adjustments and adaptations. The COVID-19 pandemic resulted in a multitude of challenges at different levels. This forces a pivotal shift out of the comfort-zone; yet potentially creating opportunities for neurorehabilitation service transformation and future preparedness.
| Unmet rehabilitation needs among community-dwelling stroke survivors and implementation of early supported discharge program in Korea | | |
Nam-Jong Paik
Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
Community-dwelling stroke survivors have various long-term problems. These problems are often not properly managed, remaining as unmet rehabilitation needs. Among those unmet needs, identifying the “intervenable” unmet rehabilitation needs is important because it can lead to the appropriate rehabilitative service. We have conducted a survey on unmet rehabilitation needs of eight domains, namely spasticity, dysphagia, communication, cognition, ambulation, pain/discomfort, anxiety/depression, and self-care. The most frequently reported unmet needs were anxiety/depression (74.6%), communication (61.9%), and cognition (59.7%), and the total number of unmet needs significantly correlated with a lower EQ-5D index. These findings imply that non-physical needs are more likely to be unmet, requiring attention for appropriate management. Early supported discharge (ESD) is a transitional care model aimed to accelerate the home discharge of post-acute stroke patients. By providing a well-organized home-based rehabilitation service, ESD has been proven to reduce the length of hospital stay as well as long-term dependency. A multicenter randomized controlled study is under investigation to examine the feasibility of ESD in Korea. The results will include various impacts of ESD including functional outcomes, cost-effectiveness, and sociocultural aspects. The study will be able to prove evidence of the applicability of ESD in Korea.
| Long COVID 19 syndrome: A rehabilitation perspective | | |
As the Covid pandemic slowly comes under control about 4 million people worldwide have succumbed to it and about one 180 million have recovered. Recent classifications by the National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN) and the Royal College of General practitioners (RCGP) have divided Covid- 19 infection into i) acute Covid 19 infection up to 4 weeks, ii) ongoing symptomatic Covid- 19 from four weeks up to 12 weeks and iii) post Covid 19 syndrome beyond 12 weeks when symptoms and signs persist. “Long Covid 19 syndrome” includes both “ongoing symptomatic” and “post Covid 19 syndrome”.
This evolving syndrome involves multiple organ systems – brain, lung, heart, skin and in addition manifests as generalised non-localising symptoms of fatigue, post exertional malaise, cognitive abnormalities (brain fog), sleep disorders, impairment of concentration, and joint pains among many others. All of these which evolves and persists after the acute Covid 19 and many last beyond 12 weeks lead to morbidity and limitation of activities of daily living and consequent inability to get back to work and normal livelihood.
The pathogenesis of this new illness/syndrome is yet poorly understood. Since the long Covid 19 syndrome is seen in patients with severe initial illness requiring critical care support and prolonged stay with higher incidence of comorbid conditions including diabetes, cardiovascular disease, cancers, pre-existing lung conditions and underlying psychiatric conditions and obesity, several hypotheses for long Covid 19 syndrome have been put forward. Dissemination of the virus through blood circulation into every organ system, widespread endothelium inflammation and micro thrombi formation, the subsequent immune hyperstimulation syndrome leading to cytokine storm in severe cases with associated mast cell activation syndrome leads to an excessive inflammatory response from which the consequent tissue damage takes much longer to recover. Persistent immune-mediated tissue injury due to the formation of antigen-antibody complexes in the second and third weeks when the humoral immunity gets activated may be a cofactor. Activation of autoantibodies results in lung injury and lung fibrosis in addition to the initial hypoxaemia and the effects of oxygen therapy causing superoxide/reactive oxygen species induced lung inflammation, fibrosis and injury.
Unfortunately, there is no wide awareness of the long Covid 19 syndrome even among health-care workers. This is a new disease entity and the complex immune response that has been varied between and within various geographical regions of the world and the speed with which millions of people have been ilicted by this novel coronavirus has indeed caught us unawares in the management of the acute illness iecting so many at any one time and thereby stretching and overwhelming the health care resource of every country and particularly the lower- and middle-income countries. The subsequent development of the long Covid 19 syndrome has been a further blow to society and to the already stretched healthcare resources as the expected recovery of moderately and severely iected individuals by this new syndrome was not anticipated.
Davies et al. revealed the probability of having prolonged symptoms of moderate, severe and very severe category in 37%, 15% and 5% in the long Covid 19 patients six months after the onset of the acute illness. Hence the numbers are significant potentially which will challenge healthcare resources unless we have effective resource allocation and a clear understanding of the syndrome and the rehabilitation strategies that need to be in place to initiate early recovery and prevent prolonged morbidity and societal burden. The increasing awareness of the condition and treatment interventions by medical professionals and allied health professionals, patients, members of the public and lawmakers will help to prepare and maximise the healthcare facilities in recovered subjects through a holistic care approach.
Rehabilitation management: Pulmonary rehabilitation of interstitial lung disease following Covid in patients presenting with long-term shortness of breath and cough long after the acute illness has subsided is now being defined. Cardiac rehabilitation in patients suffering from myocarditis, decompensated heart failure cardiac arrhythmias and acute coronary syndrome in addition to thromboembolic events is being realised as well. Various cutaneous manifestations as a consequence of immune activation and micro thrombi and altered microvascular haemodynamics secondary to potential autonomic dysfunction are also being recognised by internists, dermatologists and rheumatologists.
Neurological, psychiatric and neuromuscular rehabilitation: The neurological manifestations are seen in half of the hospitalised patients and in a high proportion in critically ill subjects requiring ITU care. Persistent symptoms of headache, myalgia, weakness, vertigo, loss of smell and taste to more intrusive symptoms of ongoing seizures, encephalopathy and burdensome stroke need a multi-disciplinary approach to optimise rehabilitation. “Brain fog”, an umbrella term to describe a constellation of cognitive dysfunction manifesting as confusion, short-term memory loss, dizziness and inability to concentrate is a common manifestation of the long Covid syndrome thought to be due to hypoxia and mitochondrial dysfunction leading to micro structural brain vascular damage. The psychiatric burden of stress on survivors particularly from critical care units has unmasked the entity of post-traumatic stress disorder, anxiety and depressive symptoms in nearly 35% of subjects in each cohort studied. Impaired cognition attention and concentration and sleep disturbances manifesting as reduced attention span, mental processing speed reduction, impaired concentration and memory one year later following the acute Covid syndrome has already been identified in nearly one third of that specific cohort. The generalised weakness that patients report particularly in patients receiving invasive ventilation for a prolonged period with coadministration of high-dose steroids, neuromuscular blocking agents and immunomodulators are extremely prone to critical illness neuro myopathy who then suffered from prolonged immobility and consequent disability. The comorbidities of diabetes, chronic alcoholism, chronic smoking, hypertension, morbid obesity and the metabolic syndrome contribute towards the microangiopathy and dysimmune/persistent immune dysfunction with associated endocrine/hormonal imbalance that contributes towards a persistent and prolonged multi-organ chronic dysfunction.
In lower- and middle-income countries (LMIC) in the Asia and Oceania region where 60% of the world's population live the availability of trained health care providers is at a premium. Neurologists managing the neurological complications of acute Covid 19 are few and far between and neuro rehabilitationists are even less on ground. Our allied health professional colleagues who are the real providers of the service for the long Covid syndrome iected patients are critically low in numbers across the world and severely so in the LMIC countries. In relation to the potential numbers of patients ideally requiring the services of physiotherapists, occupational therapists, clinical psychologists, speech and language specialists and social workers and many other colleagues depending on the alternative/local health practitioners/practices (e.g. In India AYUSH - Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy) in the LMIC countries it is anticipated that the combined help of all specialists will help provide universal coverage to all ilicted in Long COVID syndrome. The use of Teleneurology, group therapy, self-support therapy modules and empowerment of societal networks will ensure that no one is left behind or out and everyone is looked after. The fact that this Long COVID syndrome has an eventual good prognosis in most and does not merit anxiety and distress cannot be overemphasised. The knowledge base of this illness as it increases in the scientific and medical community will result in a better outcome of therapy planning.
A PubMed search of Long Covid and Physiotherapy showed approximately 50 publications in 2020/2021. These focus on the cognitive and emotional wellbeing as outcomes. Single case reports show a patient participating in biweekly physical therapist sessions for 8 weeks, which included aerobic training, strengthening exercises, diaphragmatic breathing techniques, and mindfulness training with metabolic equivalent for task levels increasing with variability over the course of the program. The patient's muscle strength, physical function, and exercise capacity improved. 6-Minute walk distance increased by 199 m, equating to 80% of their age-predicted distance. Quality of life and PTSD scores did not improve. At evaluation after physical therapy, the patient was still experiencing migraines, dyspnoea, fatigue, and cognitive dysfunction.
In another comprehensive survey to assess functional limitations and rehabilitation needs during and after infection with COVID-19, The COVID-19 Rehabilitation Needs Survey (C19-RehabNeS) consisting of the established 36-item Short Form Survey (SF-36) together with the newly developed COVID-19-Rehabilitation Needs Questionnaire (C19-RehabNeQ) enables collection of systematic information on patients with post-COVID-19 syndrome (Long-COVID-19). The strength of this survey is that it combines the assessment of important rehabilitation needs with assessment of satisfaction with the health services, treatment and therapy during the pandemic (C19-RehabNeQ) and assessment of patients' quality of life (SF-36).
Thus, Long COVID Syndrome is a new disease/syndromic entity and potentially will iect large numbers of people in the most populated parts of the globe and if newer variants create more havoc and the virus with its peculiar pathogenesis stays in circulation for next few years we are better off getting out act together to ensure that all of us are prepared to face its menace and provide good care to our respective populations in our region.
For that our people and respective governments will be grateful to us. This crisis response will help pave the way for better health for the future in our Asia Oceania region and new methods of health care delivery like digital health, Teleneurology and Indigenous medicine will flourish in the future and chronic underfunding of health care in our regions will potentially improve with better patient advocacy and lawmaker understanding and input into healthcare.
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