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Medical rehabilitation following an ictus-based cerebral
lesion is carried out through a recovery and learning activity aimed at
restoring independence and social reinsertion.
The purposes of the rehabilitation after a stroke also include the
prevention of complications and treatment of the clinical problems that show
up during rehab care.
The objectives of the process for each individual patient are defined
on the basis of the characteristics of the neurological damage and residual
capacities, compatible with whatever organizational and individual availability
there might be during the rehab period and taking into account the original
social ambience.
It is commonly said that the recovery curve has its peak in the first
three months, which is also confirmed by EEG studies, although recent observations
point to the possibility of improvements on the operative plan even at a
distance of some years following the stroke.
It may be helpful to point out here how post-ictus functional recovery
can be the intrinsic kind or else adaptive. “Intrinsic” recovery assumes the
rescue of impaired abilities to the extent of allowing a useful performance
of the patient's everyday basic tasks.
On the other hand, “adaptive” recovery, also known as “compensatory”
is based on ability development as compensation for the deficiencies, both by
the healthy body half and through utilizing the remaining activities of the
side stricken with disability.
In this situation, the patient can again be capable of carrying out
defined tasks without having attained the functioning of the structures
involved by the vascular damage of the encephalus. Both intrinsic and
compensatory modalities can be integrated to allow the restoration of
specific abilities.
In determining the achievable goals for each individual patient,
depending on the clinical picture, specific recovery methods have to be
provided for, conditioned by the factors that have a negative bearing on the
restoration of partial or total autonomy.
The most common “negative” predictive factors for the development are:
1) Any generally impaired state or reduced personal dependence before
the vascular event (presence of cardiovascular or respiratory disorders,
serious orthopedic problems, etc.).
2) Severe sensory deficit, especially proprioceptive;
3) Depression;
4) Impairment of cognitive abilities, whether due to an overall
deterioration or the presence of selective deficits like apraxia, sensory
neglect and anosognosia;
5) Limited availability of family or inadequate rehabilitation
structures.
On the contrary, good rehabilitative organization that involves the
family and good motivation are considered to be favorable recovery
factors.
Therefore, as already said, predictability in terms of recovery as
neurorehabilitation in the aftermath of strokes is of great importance in
establishing the reachable targets in that it achieves a better quality of
life, wedded also to functional possibilities with encouraging implications
for family, social and work relationships.
Recovery indicators: evaluation scales
In addition to clinical criteria relying mainly on evaluation scales,
there are also instrumental means with which the rehabilitator, shortly after
the ictus, can already seek to consider what the disability extent might
be.
Apart from cerebral vasculopathy prevention and on the acute phase of
stroke, there is a literature on the problems of post-ictus rehabilitation,
though there is meager information about longer-term sequelae.
Research by Giaquinto, carried out on 180 stabilized hemiplegics and
on control subjects in the same age-range, yielded the following
results:
- averages of 75% of daily activities were recovered. The presence of
depression was critical;
- the stabilized hemiplegic suffered more depression with lower social
activity than the controls (p<0.001).
Women were more affected than men were. On average, the depression was
moderate but could be serious in 14.41% of cases;
- in all patients there was a strong correlation between depression,
social activity and stress given by relatives;
- the conditions at discharge from the rehab center were predictable
regarding self-sufficiency in daily life;
- 21.42% of working-age subjects returned to work, not always to the
same tasks but very often in readjusted conditions;
- the patients were very often subject to criticisms, from those they
live with, regarding apathy, irritability and selfishness.
The undoubted progress concerning imaging techniques and
physiopathology of the brain's circulation have not brought any long-term
advantages and the patient with stabilized sequelae needs care but of a
different and broader kind compared to what was received before.
In this context, a good orientation in predictive terms may derive
from the administration of the “NIH” of the T. Brott Stroke Scale (1989).
But, as already mentioned, function assessment has particular
importance in rehab for the imposition and organization of treatment and in
the follow-up, be it short, medium or long-term (Borer and Niouri, 1989; Donaldson,
1973; Gresham, 1979, 1980), for the purpose of monitoring the degree of
disability and the effectiveness of therapy.
In clinical practice, the evaluation concept has been assimilated to
that of assessing the activities of daily living (ADL), becoming the main
measure of disability today.
This is a matter of numeric measuring scales that include aspects of
mobility, self care activities (e.g. eating, bathing, toileting, dressing,
combing hair, etc.) and, not constantly, sphincter control (bowel and bladder
continence).
An example of an ADL scale, as suggested by Katz and reckoned through
an ordinal numerical scale, examines the following tasks: bathing, dressing,
toileting, transfer movements, sphincter continence and eating).
These functions are ordered in such a way as to try to reflect the
actual sequence with which such functions are lost (and sometimes rescued) in
disease and in aging.
According to Law and Latts (1989), this scale is reliable in
describing the patient's current degree of disability and also allows
comparison among disabled folk.
One of the best known and undoubtedly most used ADL scales, is
the one suggested by Mahoney and Barthel in 1965, and commonly ascribed to
Barthel.
This is a numerical scale composed of ten items, and to each of which
a variable score is attributed, from 0 to 5 to 10, or else 0 to 5 to 10 to
15. Two different kinds of initialing are chosen as a function of the
importance arbitrarily attributed to the different parameters in determining
the total disability.
The functions considered are: eating, combing hair, dressing,
transferring from bed to chair, toileting, bathing, walking around, using
scales, and sphincter control.
The Barthel index has been employed in several functional recovery
studies, and has the plus-points of validity, sensitivity, reliability and
simplicity in describing the existing functional abilities and related
changes over time (Granger, 1979; Gresham, 1980; Wade, 1987; Law and Letts,
1989).
As highlighted by Granger et al (1989), who repeatedly measured the
Barthel index on 110 hemiplegic patients during hospitalization, the test is
also able to approximately foretell the hospital-stay period and the chances
of discharge.
It is however limited by not taking some of the factors that influence
recovery into account, such as perception, cognitive, linguistic, emotional
and family problems.
D. T. Wade et al. (1987) evaluated the functional
accomplishments of 976 hemiplegic patients using Barthel's index for a
post-event period of 6 months. It emerged from these investigations that the
Barthel score at the beginning (within the first week) was an important
prognostic, functional recovery and survival factor (whereas, according to
Basaglia et al., this index only assumes significance from the third week
onwards).
These authors also indicated that the recovery would be found to be
faster in the early weeks, though observable in many patients even in the
period between 3 weeks and 6 months.
Finally, in accordance with other authors (Prescott and Garraway,
1982; Wade and Skilbeck, 1983), urinary incontinence was an important
prognostic factor.
Skilbeck et al. (1983) investigated after-stroke
recovery in 92 patients, through ADL tests, of ambulation, upper limb tasks
and linguistic communication. The study confirmed that the best recovery, in
all the variables examined, was to be found within three months of the morbid
event.
Basaglia and Mazzini (1982), utilizing Barthel's index, looked at the
functional independence in ADL of 100 hemiplegics who underwent rehab
treatment, comparing the values achieved by discharge time with those
obtained after variable periods spent at home.
The functional index was then correlated to various parameters such as
the patient's age and sex, and the severity and side of the lesion.
The results showed that the seriousness of the lesion is undoubtedly
of prime importance in conditioning motor function capacity.
Furthermore, better functional recovery was noted in right hemiplegics
compared to left. In the light of this study, the authors in the end
emphasized the need for a specific functional test for the hemiplegic in
order to avoid a homogenization in the results, which inevitably happens to
functional activities considered too globally (e.g. eating, dressing, etc.). Also
suggested, was the exclusion of sphincter control appraisal, given the sparse
incidence of this alteration in these patients.
Schoening et al. (1965) proposed a simple numerical ADL scale, known
as the Kenny Self-Care Evaluation, which is made up of six functional
categories (bed mobility, transferring movements, locomotion, dressing,
personal hygiene and eating), investigated in their turn in different trials
involving 18 items in all. To each one, a score is given that can range from
0 (dependent) to 4 (independent).
In this scale, each category is regarded with the same importance and
the reciprocal relationship between the need for nursing and functional ADL
independence is emphasized (Gresham, 1980). Compared to Barthel's test, the
Kenny Self-Care Evaluation does not include sphincter continence among the
factors considered.
In a recent critical review of the ADL scales, Law and Letts (1989)
confirm the validity of Kenny's scale and its usefulness for descriptive and
predictive purposes, as well as the option it presents to follow changes in
the patients' functional ability over time. This was the scale used by Stern
(1971), who examined 62 patients affected by vascular hemiplegia, treated in
a rehab setting and making use of clinical testing of motor ability,
sensitivity, strength and ADL functional tests. It was revealed how
improvement occurs for most in the first two months following the ictus. This
would basically be explained on the functional plane, independently of the
presence of an intrinsic sensomotory recovery, which in many cases appeared
negligible. The author concludes by attributing a dominant role to the
rehabilitation intervention within the ambit of adaptive recovery and
considering the current rehab techniques as little effective in themselves
for modifying the neurological deficit.
All this underlines the significance of the definition of unequivocal
operational criteria in rehabilitative medicine, especially in terms of
improved predictability regarding the nature of the disabling outcomes.
Moskowitz and McCann (1957) drew up the PULSES profile (Physical
condition, Upper limb function, Lower limb function, Sensory components,
Excretory function, Support factors), which was then adapted by Granger et
al. in 1979. This is a matter of a scale where 6 main aspects are examined:
the subject's general physical condition, the upper limb function (self-care
activities that are mainly arm-dependent), lower limb function (mobility and
transfer movements), sensory components (relating to communication and
sight), sphincter function, and support factors that are psychological,
emotional, familial and social. A score is allotted to each item ranging from
1 (functioning intact or independent) to 4 (completely dependent).
Granger et al. applied the PULSES profile and the Barthel index to a
group of 307 severely disabled patients due to various disorders, for the
purpose of measuring their degree of handicap and monitoring their recovery. The
results confirmed the validity, reliability and sensitivity of both methods
in describing the functional abilities and the related changes over time. Since
the PULSES profile also includes sections on both medical and social problems,
it cannot be regarded as a true ADL scale (Barer and Nouri, 1989). However,
it does deserve consideration, since it is widely used in clinical practice,
also in terms of predicting outcomes, not only for hemiplegic patients but
also in other handicapped conditions like cranial traumas.
In a study conducted by Moskowitz et al (1972), the authors evaluated
neurological and functional recovery in 518 stroke patients, 313 being
followed for 3 years using the PULSES profile. The results indicate that
neurological recovery peaks within 6 months and that it does not always
coincide with functional recovery. The patients studied underwent rehab
treatments that were extremely varied (from home-based therapies to stays in
rehab centers that were specialized in stroke cases); recovery seemed to be
independent of the type of treatment received.
Another functional assessment system not limited to ADL alone is the
ESCROW profile (Environment, Social interaction, Cluster of family members,
Resources, Outlook, Work/school/retirement status). This analyses the
capacity to utilize the joints, communicate and see, as well as whether or
not physical therapy and/or nursing care is needed and the level of social
care.
The ESCROW profile, PULSES and Barthel's index together form the
Large-Range Evaluation System (LRES), as conceived by Granger et al. (1976).
This is an assessment means to determine the services needed, the degree of
invalidity and individual changes over time, in order to compare the
conditions of treated patient groups at different times and in various
locations, and also to tease out some pointers in terms of outcome
predictability.
Several other ADL evaluation scales are to be found in the literature,
and the reader is referred to a recent review by Law and Letts (1989), in
which some 13 ADL scales are examined in detail.
Wade et al. (1983) upheld the importance of accurate
prediction of the post-stroke situation for rehab and the need for a suitable
medical model. Two basic methods are recognized for this. A first approach
consists in connecting a single initial factor with the final result: the
initial variable may be quantified (e.g. the side of the cerebral lesion by
CT-scanning), or simply recorded as present or absent (e.g. whether or not
hemianopia is present). With this method it is possible to identify many
variables that are individually linked but none of which allows an accurate
prediction to be made. The second approach provides for the identification of
a group of aspects that are relatively independent of each other, yet when
taken together is connected with the outcome. However, the initial variables
identified and their relative significance can differ substantially from
study to study, with no clear consensus among the scholars on this point. One
example of such a method is the mathematical technique of multiple regression
analysis that has been employed by several authors. Among these, Fejgenson
carried out a predictive survey on 841 stroke-affected patients. The model
put forward by the author foresees the ADL performances, walking ability and
the period spent in hospital as dependent variables, and a series of factors
such as age, sex, etiology of the stroke, severity of the hemiplegia,
presence of hemianopic, sensory, perceptive disorders, etc., as independent
variables.
The increasing employment of the Functional Independence Measurement
(FIM) over the last decade has allowed better communicability of this
appraisal method. Besides considering the psychic and cognitive problems, through
numerical evaluation (from 18 to 126), it allows the debilitating picture to
be monitored longitudinally.
However, the inadequacy of considering medical and physical variables
alone is becoming increasingly obvious, especially for the outcomes of strokes.
There is now clearly a need to include socio-economic variables in the
analysis, as well as instrumental tests, for boosting the predictive efficacy
of the model.
Instrumental recovery indicators:
There are recent works, among them Bastianello et al. (1993), which
signal that functional recovery in a patient with ischemic stroke depends on
various factors such as age, general condition and, especially, the site and
extent of the cerebral parenchyma sufferance. Such authors underline the fact
that with CT scanning it is possible to observe, even within a few hours of
clinical onset, any sufferance of the cerebral structures, being able also to
predict the extent of parenchyma damage and eventual functional recovery. In
this way it is possible to identify categories of patients having different
functional recovery potential. These studies suggest how the presence of
initial parenchymal signs is indicative of a more extended lesion; an
expression therefore of a negative prognosis, unlike patients with CAT in
negative acute phase or with a decidedly encouraging prognosis. These are
highly relevant aspects in the programming and orientating of rehabilitation
treatment.
On the basis of these premises, it would seem very useful at the
conclusion of a diagnosis and rehabilitative prognosis to combine the various
evaluation scales with (apart from imaging diagnostics, no matter how
sophisticated [CAT, NMR, Angio NMR, SPECT, PET]) instrumental investigations.
The latter are a check both on the neurophysiological and neuro psychological
planes and for such things as posture, dynamic co-ordination, walking step
studies. These are aspects not to be relinquished by any rehabilitator who
desires to best monitor and quantify the disabling pictures in ictus patients
and who has to formulate an exact rehab prognosis.
In compliance with such needs, the above elements are particularly
overseen by Bari University's Physical Medicine and Rehabilitation
Operational Unit (O.U.), at the Azienda Policlinico (General Hospital Trust)
and are further explained below.
A) Neurophysiological aspect: The elaboration of signals is a
many-faceted undertaking and there are few areas with a system of pointers
more complicated than the human body.
Seeking to record the activity of a single motor unit, the base
element of a muscle, is like trying to pick out a slightly out-of-tune tone
in a chorus of many voices. But using dedicated software for the elaboration,
one can in fact isolate that “soloist” voice.
Thanks to such analysis programs, the checks and clinical care for a
wide range of neuromuscular disorders have made exceptional progress.
Electromyography (EMG) equipment is now standard in the better-fitted
clinics. These instruments monitor the nerve signals and the muscular and
neurophysiological activity can utilize EMG procedures to establish when a
muscle is active and measure the force exerted during a specific movement. The
measurements indicate if the motor malfunction is due to a muscular or
nervous disturbance, or both. The only problem is that current EMG equipment
is not sufficiently precise. The electrodes detect the muscular activity of
different motor units that all react in the same instant but at slightly
out-of-phase times. Evaluation of the muscle tone usually excited in the
aftermath of a stroke is one of the aims in EMG investigations.
A fundamental task in signal elaboration, but complicated to apply, is
to obtain the analysis in frequency and uncouple the input channels. Strong
phase couplings not only make the uncoupling difficult, but work things in a
way that the conventional spectral analysis methods exaggerate the peaks at
low frequencies.
Nevertheless, it is the low frequencies (below 40 Hz) that contain the
information on the activation rhythms of the motor units (MU). Several
methods have been tried for the breakdown of signals, but so far have only
worked with low muscular contraction levels. Moreover, these procedures call
for the electrode needles to be inserted into the muscle, which is rather
painful.
A step forward is the application of signal elaboration potentialities
by the software to the EMG surface data. The result is a completely painless
method. The two main factors that influence muscular strength output are the
amount called upon (the degree to which the motor units close to the nerve
endings are activated by the nerves), and the inducement rhythm (the speed at
which the nervous impulses react or stimulate the muscle group). Most
electromyographs simply measure and visualize temporal series data in the raw
state or lightly filtered. All this is inadequate, first because it is
difficult to deduce precisely the reaction rhythm from the temporal series data,
and secondly because the crossed connection effect of the nearby electrodes,
that pick up attenuated and dephased versions of the same signals, make it
difficult to determine which motor units have actually been enlisted. The
solution to the problem could be to use bispectral analysis.
This technique not only provides precise filtering of the low
frequencies, but also a function known as “crossed bicohesion”, that can be
used for decoupling the input channels. The EMG data is collected by means of
a traditional electromyograph, digitized and memorized, then sent to a
workstation for software analysis.
The realized algorithms are able to resolve the spectral analysis
problems; however the ultimate aim is to provide the EMG information in a
clear and accessible form.
The graphics in color polar co-ordinates may be the ideal solution. Every
portion of these graphics represents an input channel. The radius corresponds
to the reaction velocity (0-40 Hz), while the color indicates the strength of
motor activity at that frequency, instantaneously displaying which muscle
groups are “working to the maximum” and which are not.
Obtaining data in this format makes further diagnostic checking
possible. For instance, “pattern recognition” methodology may be applied in
order to compare a patient's graphics in polar co-ordinates with reference
controls related to known conditions, as in the outcomes of strokes.
Similar signal processing problems are encountered in brain wave data.
One would like not only to know which centers in the brain are active, but
also how the activity is shifted from one cerebral zone to another.
The objective is to unearth important information on the
physiopathology of the central nervous system (CNS) based on the elaboration
of EEG signals and the evoked responses to sensory stimuli (acoustic, visual,
somatosensory) and event-correlated responses (following known stressors,
motor stimulations, perception procedures, etc.). Signal-processing methods
have been introduced that are original compared to the classic numeric
filtration and synchronized media methods.
The latter, in fact, do not generally give a satisfactory signal-noise
ratio for research purposes and are incapable of assessing the dynamics of
the CNS response and therefore of measuring, after cerebrovascular accidents,
its characteristics of adaptation and plasticity. This is why a method has
been prepared that does lead to obtaining the response to an individual
stimulus.
Applications of these methods were introduced in the monitoring of
various disorders characterized by sensory response instability (e.g. central
neurological disorders and perception disturbances, in the study of training
for various motor tasks, in cognitive exercises and in the rehabilitation of
psychophysical handicaps).
Utilizing an algorithm for the recognition of the “spikes” and
changing the type of graphic from polar co-ordinates to a standard curve
graph, it is possible to get a color representation of the EEG data relating
to 14 parts of the patient's cranium.
The fundamental aim of the research is to integrate the EMG/EEG
techniques for the diagnosis, evaluation and therapy of biofeedback, with the
clinical neurology research and the rehab applications.
A final notation concerns the applications in rehab of the correlated
stimulus-evoked potentials (SEP, VEP, AEP, genitocortical and sacral) and
correlated events (NCV, P300, P400) able to assess any impairments along the
nerve channels, longitudinally monitoring the improving or worsening
developments. In addition, the P300 and P400 allow checking of the changes
that precede and accompany the elaboration of a kinetic or verbal project
permitting, for example, the appraisal over time of debilitating aspects such
as USN or aphasia consequent to the stroke.
Finally, the use of the motor-evoked potentials (MEP) with a
high-frequency magnetic stimulus means that the perviousness of the efferent
ways can be examined, not only at the conclusion of diagnosis and rehab
prognosis, but also for promoting within the nervous system, with
contemporaneous recovery training, a resulting neosynaptogenesis in the
re-conquest of motor acts.
B) Neuropsychological aspects
Concerning the superior nerve functioning alterations that might show
up following an ictus episode, investigated and subsequently subjected to
rehab treatment are the aphasia syndromes, praxic and gnosic disorders and
unilateral spatial neglect (USN) syndrome. This is done through standardized
protocols and others used experimentally at the O.U.
The preliminary explorations are on the residual potential, i.e. “what
has remained intact in the patient”, which is useful data for the recovery
prognosis.
This is done with the aid of the clinical imaging findings and
neurophysiological tests.
For instance, in right-handed subjects with aphasia and focal damage
in the left hemisphere, visual-spatial and automatic language abilities are
examined, as well as other, supramodal abilities to do with the right
hemisphere.
Moreover, with the help of investigations like the Aachner aphasia
test (AAT) and Miceli and Laudanna's procedures for the analysis of aphasia
disturbances (PAAD), the rehabilitator can glean useful information about the
“residual” linguistic skills (morpho-syntactic, semantic-grammatical,
prosodic and lexical). As a corollary, the scale for assessing the aphasic
patient's quality of life is utilized in the “SF-36” and FIM for “setting”
both the care assistance loading for the incapable patient and identifying
the degree of handicap that would bear on the state of health.
In the same manner, in subjects having lesional damage to the minor or
non-dominant hemisphere, tests are administered for the evaluation of
body-image hemi-somatoagnosia, clothing apraxia, visual and auditive
hemi-inattention, and hemipokinesia that evaluate USN syndrome and,
afterwards, an ad hoc rehab protocol is proposed for rescuing the visual
perception, attention, mnestic and praxic disorders for the target of having
better autonomy in daily life activities. Increasingly added in recent years
are tests yielding information that also allows, with computer assistance,
the extension of the investigation to the attention aspects, which can also
be assessed with reaction times.
Multidisciplinary teams are made up of a physical therapist,
neurologist, psychologist, physiotherapist, occupational therapist and
logopedist.
For several years now, under the guidance of the O.U.'s psychologist,
the aphasia patients have been taking part in experimental group
psychotherapy meetings that function as psychological support and
optimization for the rehab efforts.
Psychodiagnostic and psychotherapeutic interventions for couples and
families are also carried out in the other disabilities manifested by the subject
having hemispheric lesion damage.
C) In the last decade, new, reliable and repeatable clinical
instruments have been introduced, both for the objective evaluation of the
seriousness of balance disturbances and for the study of the walking step and
the effectiveness of the pharmacological and (above all) rehabilitation
therapies.
In a first phase, semi-quantitative clinical measurement scales for
the upsets to posture control and/or the functional limitations deriving from
motor capacity alterations (FIM, Barthel, Norris, etc.).
A second approach has been the instrumental one based on assessing the
shifting of the body's barycenter or center of gravity and of the plantar
support by means of a dynamometric board or platform. Indeed, studying
postural control with a platform of forces permits evaluation of the role of
the sensory information (visual, proprioceptive, vestibular), as well as the
subject's stability boundaries with suitable modifications to the evaluation
tests.
Currently, an instrument is available, put together with the study and
monitoring of subjects affected by postural disorders: electronic
baropodometry (EBP).
This procedure, introduced to Italy some years ago, has been
re-proposed in 1999 with the system known as “Clinical Software I & II”
and incorporates:
- a modular baropodometric detection platform (MBP120), comprising a
walk-along trench (320 x 75cm) with acquisition software for static, dynamic
and posturographic readings; automatic data interpretation; IBM-compatible
PC, monitor and printer.
- Imaging system for acquiring images and real-time replays of the
posturographic examination (standing static) and the deambulation (standing
dynamic), calculation of the length and angles of the various body
segments.
This offers the chance to appraise the plantar pressure distribution
with upright gait, both in static phase and whilst strolling (Fig.
1), providing in color the values of the pressures, the peak pressure
point, the support surfaces, the body's barycenter, the one passing
on the perpendicular of each limb (to show up any rotations or dysmetria
of the superstructure) and the dynamic one (resulting from the forces).
In order to study the static support, the patient is made to mount the
platform (with or without shoes).
Proprioceptive recovery will be appropriate firstly, inviting the subject
to stroll for a few minutes on the modular platform: during the acquisition,
the bipodal support should be spontaneous, with the arms kept at the
sides of the trunk, looking straight ahead, backs of feet aligned, the
medial edge of the foot equidistant from the axis of the ordinates,
Chopart coinciding with the axis of the abscissas. Such support is visualized
after having calculated the average of the oscillations over the acquisition
time.
The patient is subsequently prompted to walk on the modular footboard
made up of 4,800 resisting matrix sensors in order to carry out the
dynamic examination.
Acquisition begins when the foot touches the platform and, after having
memorized many consecutive steps, ends when the patient gets off the
platform.
During the stepping movements, the pressure points of each foot are processed,
subdivided into a hundred phases (from the back of the heel to the forefoot).
The posturographic evaluation (Fig. 2), moreover, becomes fundamental
in the study of the co-ordination capacities of an upright-standing
subject (dynamic phenomenon), which is based on the control of a slow
and steady body sway with the fulcrum at the tibio-tarsus, which allows
a muscular, tendinous and ligament re-adaption, granting short rest
periods to the supporting tissues. The posturographic test features
the recording within 60 seconds of the postural sway of an upright subject,
and informs us about some basic parameters:
- oscillation surface areas expressed in cm2;
- length of the oscillation skein expressed in cm (the value is
correlated in a directly proportional measure to the energy spent by the
tested subject in maintaining the basic posture);
- maximum and minimum values for the shifts in the pressure center on
the two Cartesian axes (X and Y);
- “Status-kinesigram” (graph representation of the shift in the center
of pressure in a Cartesian axes-skein system);
- “Stabilogram” (graph representation of the pressure center shifts
over time, compared to the single Cartesian axis);
- Graph tracking the oscillation velocities;
- Graph representation in percentages of the oscillation frequencies
expressed in Hz;
- Graph of the compensation cycles;
- Radar control.
It is also possible to survey any destabilizing effect induced by the
perturbation of one or more sensory inputs with several other complementary
stabilometric tests that have the purpose of individuating the contribution
of single sub-systems, such as the oculomotor, stomatognatic component
relating to the cervical, dorsal and lumbosacral spine and to the lower
limbs, etc.
Its employment can find preventive, diagnostic and therapeutic applications.
Preventive applications: concerning pre-school and school-age subjects
for the screening of orthopedic/neurological disorders.
Diagnostic applications: providing “quantitative and qualitative”
data on the postural deficit in patients having orthopedic conditions,
such as spinal dysmorphisms and paramorphisms, spondylolysis and spondylolisthesis,
congenital dysplasia of the hip, valgus knee, arthrosis, congenital
deformed foot, valgus flat foot, valgus great toe, arthrosis, osteocondrosis,
rheumatoid arthritis, traumatic noxae outcomes (fractures, luxations,
distortions, muscular and tendinous lesions); and patients with neurological
disorders, such as hemiplegia, multiple sclerosis, infantile cerebral
paralysis, Parkinson's disease, outcomes of poliomyelitis, diabetic
neuropathy (for early diagnosis and monitoring of plantar ulcers), myopathies;
and subjects with odontostomatognatic defects, such as malocclusions,
dysfunctional algic syndromes (myofacial syndromes, bruxism, condyl-mensical
disco-ordinations, “ATM” arthrosis).
Therapeutic applications: on the one hand these allow appraisal of the
postural improvements achieved by the employment of neuromotor rehab
techniques, orthopedic surgery (carrying out the examination pre- and
post-op); and so too, the assessment of subjects having ortesis; on
the other hand, they can be employed as therapeutic measures, e.g. as
a biofeedback method.
In this context it is appropriate to mention some studies conducted,
using EBP, in a group of patients affected by a stroke's after-effects.
In fact, patients having hemisomatic deficit were enlisted (50 hemiparetic
patients - 26 female and 24 male - 26 of whom had right hemisomatic
deficit, with mean age 60.5 years) who maintained the upright gait and
walked.
After physiatric evaluation, they underwent static, dynamic and posturographic
baropodometric assessment. The resulting data was set against
a homogeneous group of subjects (27 females, 23 males, mean age 59.7
years) having no noteworthy afflictions. The data unearthed by our study
was subjected to statistical analysis that studied the variance to a
reasoning and test by Bonferroni.
With this trial in the disorders considered, EBP highlighted the various
plantar support possibilities, taking into account the surfaces and
load distribution in bipodal support.
As regards the patient group with hemisomatic deficit, significance is
regained concerning the maintenance of the load distributed bilaterally
to the back of the foot (Fig. 3), especially on the healthy side;
but careful evaluation of the data reveals a more reduced load to the
paretic side of the patients with left hemisomatic deficit (right cerebrolesis)
compared to those having right deficit (left cerebrolesis).
Significance is also regained in the posturographic assessment (Fig.
4) regarding the values of the oscillation surfaces and length of
the step mark. Indeed, the two values considered are clearly greater
compared to health, while the length of the step mark is, interestingly,
decidedly lower in the left cerebrolesis patient compared to the right.
At this juncture it serves to point out that the length of the step trace
is an expression, as already referred to, of the energy spent by the
subject for co-ordination maintenance, both static and dynamic. Thus
the right cerebrolesis patients, in order to best optimize the basic
posture and kinetic co-ordination challenged or invalidated by the motor
deficit, have to utilize more complex and costly postural compensation
strategies from the energy viewpoint.
This datum confirms a hypothesis already put forward with studies (Megna
- Ranieri) also signaling levels greater than the encephalic trunk supraspinal
level as essential to the ends of postural control: a function highly
learnt and adaptive, strictly connected to the internal body image,
fully corticalized in the right parietal area.
Therefore, in
the aftermath of strokes, EBP is useful for monitoring the reintegration,
by means of a targeted rehabilitative intervention, of the indispensable
key postural reactions, above all in the left hemiparetic (very often
afflicted with unilateral spatial neglect) for the passage from a motility
that is primitive, poor, global and stereotyped (and challenged too
by the pathological synergies), to one that is more evolved and free
in operative choices.
Therefore EBP presents
itself as a remarkable method having manifold applications, but which is
still limited by the construction of a “normal range”, as much for the static
analysis as the dynamic analysis.
Indeed, only through surveys
of a large number of subjects and with an adequate statistical data
processing, will the interpretation of results be improved.
From what has been said
so far, the need emerges for a correct diagnosis and rehabilitation prognosis
that would guide the rehabilitator towards various options according to the
degree of disability.
However, the choice need not
be embarrassing, but should follow some precise criteria defined on the basis
of the goals and outcome predictions that, on balance, it suggests to us.
a) If the prediction is
based on the objective, e.g. to go back home, it cannot be correlated to just
the physical measure but also to be considered are the family ambience, the
so-called home setting and the furniture and fittings, the chances of having
care assistance and the care-giver.
b) If the prediction is
based on the quality of life, the aim should be to reduce the patient's
disability, handicap, depression and stress and also the relatives' stress.
c) If the prediction is
based on the cost-benefit ratio, there is a need to have measures of the
results, outcome, and control of the resources made use of. These include
those linked to the structure, building work (wards, gym, swimming pool,
Robinson garden, dining hall, recreation, bathroom and kitchen facilities,
religious needs, pharmacy).
Then there are human
resources (medical personnel, paramedics, rehab therapists, occupational
therapists, logotherapists, encouragers, hairdressers) and instrumental
resources (radiology, neurophysiopathology, TENS, FESS, foot-wells, etc.) as
well as furniture (beds, wardrobes, bedside cabinets, bath-chairs, etc.) and
consumables (special mattresses, sheets, incontinence-wear, condoms, toilet
items, etc.).
d) Moreover, the opportunity
of being able to avail of instrumental tests like EEG mapping, such as to
contribute to anticipating the evolution of a disabilitating picture related
to the stroke, becomes fundamental for the planning out of the therapeutic
iter. As already mentioned, it is worth underlining that the concepts
of process and outcome are not totally unitary but, rather, show signs of the
objective that is proposed in the course of the rehab care, a condition
extremely useful for both the neuro-rehabilitator and the patient and his/her
family. The neurophysiological aspects were dealt with by Dr. G. Ianieri,
neuropsychological considerations by Dr. P. Fiore, and the facets to do with
posture, dynamics and the step cycle were by Dr. M. Ranieri.
Megna Gianfranco
Fiore P.
Ianieri G.
Ranieri M.
Dipartimento di Scienze
Neurologiche e Psichiatriche
Sezione di Medicina Fisica e
Riabilitazione - Universitą degli Studi di Bari
Unitą Operativa di Medicina
Fisica e Riabilitazione - Azienda Ospedaliera Policlinico Bari
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