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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 and with intimacy of biochemical processes, peeling the nucleus and decoding the genetic code.

Adding the avalanche of modifying disease drugs and the technological progress in orthotics and prosthetics, its understandable why its so difficult for the neurologist or neurosurgeon to establish a therapeutic plan which includes the right place for balneal rehabilitation.

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Balneal and physical therapy is acting on disease phenomenon not simply in causal sense, whereas between the therapeutic mean and pathologic process is standing the affected body as a whole, with its own multiple regulation systems and reactivity. Activation of these complex systems by the natural factors is influencing cause-effect correlation, which establishes between the therapeutic agent and the affected organ/function.

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The difficulty in assessing therapeutic effects is given by the fact that balneal therapy is a therapeutic complex, which includes, beside known factors (mineral waters, mud), change of climate, habitat, diet, lack or diminishing of daily stress. All these factors influence differently the final result of the treatment.
Complex adaptive responses of the body functions to systematic, sequential, dosed application of some stressing factors (thermal, chemical, mechanical) on skin or mucosa represent adaptation therapy.

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The methods of balneal therapy are mostly traditional methods, based on a long time observation and having specificity for each resource: climate, mineral waters, different types of mud, therapeutic gases. Though, the group of methods used in spas rehabilitation departments 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 vector has a natural origin. It can be added the presence of bioclimatic elements: sun lightening gradient, humidity, atmospheric pressure, partial pressures of gases, the presence of aerosols and/or ions, radioactivity, etc. The rehabilitation cure is placed in time after hospital/ambulatory moment, where are solved diagnosis problems or emergency intervention. The patient must arrive in balneal resort diagnosed and with stabilized vital functions.

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Choice of the adequate moment and place for the 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 must ensure: - maintaining of its own structural and functional integrity, at least the rest of it; - regulation of the information flow from peripheral receptors to control systems, in case that some (or all) of them are affected: information receiving, transmission pathways, control modalities; - fast and appropriate functional response to the changes of environment; - rapid and specific coordination and integration of the other organs and systems activity with change of ambient conditions; - informational, structural and energetic substrate of complex functions: thinking, intelligence, memory.

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Requirements mentioned above outline reactive particularities of the patient with neurological or neurosurgical impairment. Especially neurological disease is modifying relationship that patient establishes with 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 of neurorehabilitation is the main affected structure itself, so that the results depend on the correct evaluation of biological adaptation capacity and of the right choice of the moment and place for therapy.

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The indication for rehabilitation cure must be done after the physician has properly analyzed the impact of each factor upon the patients body. The same way of thinking must be followed by the balneal therapist, who is prescribing and following up the treatment. The natural therapeutic factors are: - climate - mineral waters - various types of mud - therapeutic gases

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Climate
Climate represents all physical (cosmic, atmospheric, terrestrial) and biological factors, that characterize an area and act together upon humans. The climatic elements which are influencing the body response are: temperature, humidity, air movements, sun radiation.

Small variation of these factors is neutral or sedative for the organism, being compatible with impaired functional status of neurological/neurosurgical patient and with therapeutic aims of rehabilitation. Beyond the tolerance limits of the patient, the factors become stimulating; over threshold values they are becoming stressful and thus contraindicated 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 comfort index is referring to a complex

relationship between temperature, humidity, and wind on one side, and thermal sensation perceived by the organism on the other side.
Bioclimatic stress outlines oscillation limits of main

meteorological elements; inside these limits human body is 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 climatic elements 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 the adaptive systems; these areas are best choice for neurorehabilitation - exciting climate, found over 1000 m high and around prairies, requires much more body adaptability and its not recommended for neurological impairment - tonic stimulating climate, has mixed elements, depending on the season. It can be found on the Black Sea side, where in autumn and spring patients can go for balneal cure.

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Its necessary considering the impact of climate upon the organism, especially for the first rehabilitation cure, in patients with severe neural traumas, complex traumas with neuralvegetative impairment, cerebral-vascular diseases and central degenerative diseases. Special attention must be paid to acute perturbation of consciousness status (epilepsy), which can be associated with above mentioned pathology; sometimes first crisis can appear in the spa resort, as a result of accommodation to the climatic stress.

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Mineral waters

Mineral waters are natural solutions of salts, ionic dissociated or not, in balance at the source. The conditions of a declared mineral water are: - to contain al least 1g salts/l; - to contain solid or gaseous chemical elements with therapeutic action scientifically proved; - the temperature of the source must be minimum 20C; - to contain microelements. There are many criteria used for classification of mineral waters as: concentration of salts, temperature, chemical composition.
Therapeutic lakes are waters with various mineralization, which can be used for swimming, for prophylactic/therapeutic/rehabilitation aim.

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Muds

Muds are natural plastic aggregations, rocks of pasty consistence, used as therapeutic remedies. They formed either by means of underwater depositing of organic or inorganic material (curative sediments) or by dissolution of some rocks under the action of atmospheric 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 sedimentation of 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 application having characteristic indications, effects and therapeutic consequences. Temperature of water (therapeutic bath) to which thermoregulation mechanisms are minimum solicited is called thermal neutrality. There are different types of bath, depending of temperature: - cold baths in lakes or sea, associated with cold mud ointment - neutral warm baths, most frequently used in neurorehabilitation - hyperthermic baths

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During neutral warm bath the organism undergo forces corresponding to physical laws of Archimedes 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 striate muscles. 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 correct therapeutic choice are: Age General functional status of the organism Neuro-mio-arthro-kinetic and others systems and organs functional residual Education level and compliance of the patient Sometimes, patients can be very demanding about the number of procedures per day or the maximal parameters, but the balneal therapist has to manage the situation with ability and patience.

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Techirghiol Lake is a salted lake situated in the southeastearn part of Romania, famous for its therapeutical effects due to the natural deposits of saprogenic mud. In Balneal and Rehabilitation Sanatorium of Techirghiol we are treating patients with neurological/neurosurgical impairment using mud 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 therapeutic swimming pool with salted water, heated at 35C (neutral thermic), where patients perform exercises guided and helped by qualified stuff. Programs are individualized by medical prescription, but there are also working groups for the patients whos neurological damage is less severe and need no help.

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For patients with neurological severe disabilities we are using bathtubs with special forms (butterfly). For patients with less severe sequelae and associated cardiac, vascular diseases we are using simple bathtubs. Mud application is done frequently as general neutral warm baths. Salted or herbal baths are prescribed alternatively with warm mud baths. Kinesiology performed in the gym room is applied individually or in groups of 2-6 patients with similar diseases, supervised and helped by the physical therapist. Working in small groups awakens 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 order to 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 neurorehabilitation 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 other associated 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 infectious cause (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 the mentioned situations, can benefit from the effects of natural factors, correctly applied as neuro-rehabilitation cure.

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Thank you for your attention!