MULTIPLE SCLEROSIS (MS) REHABILITATION

What is MS Disease?

MS is an autoimmune disease that occurs as a result of the attack of one’s own cells against his own brain and spinal cord as a result of a disorder in the immune system.

MS is an autoimmune central nervous system disease characterized by inflammation, destruction of the myelin sheath and axonal damage. MS, which is a chronic disease, is 2 times more common in men than in women. While some of the disease progresses with attacks, some of it shows a progressive course.

Various symptoms such as limitation of movement, weakness, partial paralysis, imbalance, speech and vision disorders are seen in multiple sclerosis.

MS is a disease of the central nervous system, namely the brain, spinal cord and nerve fibers associated with vision. In MS disease, nerve fibers called white matter in these areas are affected. White matter consists of fibers that provide communication within the central nervous system itself and between this part and other parts of the body.

What Causes MS Disease?

According to our current knowledge, the cause of the disease is not known exactly. Although some theories have been proposed regarding the development of MS, none of them can explain the event completely.

Genetic factors have a great effect on the development of MS disease. However, studies have not found a specific gene that can cause the disease.

It is interesting to determine the relation of MS disease with diseases such as thyroid / goiter, SLE (systemic lupus erythematosis), mystenia gravis, diabetes, ankylosing spondylitis, inflammatory bowel diseases, scleroderma and Behçet’s disease. Because autoimmunity is responsible for most of these diseases.

• Environmental factors; insecticides, herbicides, exposure to mercury, organic solvents, and some environmental toxins we may not even know about.
• Ethnicity; The frequency of yellow and black race is lower than white race. While it is more common in Northern Europe, America and Northern Canada, it is less common in the equatorial region.
• The effect of viruses, especially herpes group viruses, although blamed, has never been proven.
• Genetic factors; the incidence of the same disease in the child of a mother or father with MS is 7-10 times higher than in the same age group in the society. However, genes alone are not a factor in disease formation.
• Inheritance.

What are the Symptoms of MS?

MS disease is a disease that progresses in different ways, with symptoms that can vary in each patient. The timing of the disease, the location in the brain and / or the spinal cord, differences in the severity of symptoms are characteristic of MS disease.

The present symptoms in the patients continue with a course with attacks and improvements. Over time, the symptoms intensify and progressively worsening. In MS, which has very different symptoms according to the affected area and the person’s immune response, following symptoms are observed;

• Numbness, tingling, pricking sensation
• Loss of strength,
• Muscle spasm, muscle stiffness, cramps and pain (loss of strength can be in the arm and leg on one side of the body, or in both legs)
• Quick fatigue and prostration
• Vision loss, double vision
• Urinary incontinence, constipation,
• Swallowing disorder
• Depression
• Speech disorder, depression, fatigue
• Sexual dysfunction
• Loss of balance, nausea
• Short-term memory loss.

The first symptoms in MS patients usually begin with vision loss of varying degrees.

How Is MS Disease Diagnosed?

It is not easy to diagnose MS disease. Because there is no specific diagnostic test and method for this disease. The diagnosis will be made with a good neurological history, examination findings and tests as in many diseases. In diagnosis, MR, CSF examination, evoked nerve responses can be controlled (in evoked responses, nerve conduction velocities are measured). In the cell where the myelin sheath is damaged, the nerve conduction velocity will also be slower.

How Is MS Disease Treated?

Today, treatments for disease, fatigue and exhaustion are performed in the treatment of MS.

Especially walking problems and loss of balance are among the reasons that limit daily living activities. Restrictions in activity will increase the likelihood of some risky diseases such as obesity, diabetes, osteoporosis and cardiovascular diseases by causing inactivity. For these reasons, regular exercise will be very important in preventing MS disease, increasing the quality of life and making the person feel good, as in all phases of life. Each patient should be evaluated separately and exercise programs should be prepared accordingly.

Rehabilitation plays a very important role in MS patients. Exercises and walking aids should be given to increase functions following acute attacks, and attention should be paid to in-bed positioning in patients who have advanced and lost their ability to walk. Detailed programs should be prepared, including programs for respiratory and trunk control, transfers and increasing upper extremity strength.

In rehabilitation;

• The patient’s body awareness should be developed,
• Abnormal muscle tone of the patient should be reduced,
• Exercises should be started with positioning or stretching,
• Sensory losses should be helped to reduce,
• The intensity of the exercises should be from simple to difficult,
• Functional skills should be practiced for daily life activities,
• Walking should be improved with walking preparation exercises and assistive devices.
• Patients should be approached in a multidisciplinary way.

Exercises applied in MS disease are effective in treating and alleviating the symptoms resulting from the disease. For this purpose;

• Stretching exercises (given to reduce muscle tension and prevent joint movements)
• Posture exercises (working the deep muscles. These muscles are very effective in maintaining balance and walking)
• Aerobic exercises (work large muscle groups, support heart and lung function).
• Strengthening exercises
• Endurance exercises (exercise given to increase the endurance of the muscles or the respiratory system)
• Balance, walking, water exercises
• Home exercise program should be planned specifically for each patient with MS.

Patients with swallowing disorders should be treated, care should be taken to ensure a balanced diet. If the patient has a bladder disorder (incontinence and inadequate emptying), medication should be given and the bladder should be emptied with the help of catheters at regular intervals.

SPINAL INJURIES

The spine consists of bones called vertebrae, which are connected to each other by soft tissue, joints, and intervertebral cushions (discs). Spinal cord injury takes place within this protected bone structure.

This chain of vertebrae allows our body to stand upright, tilt and rotate sideways. In addition, the ring bone structure at the back of each vertebra protects the spinal cord against dental factors, while at the same time allowing the spinal cord to pass through this gap.

The spinal cord consists of the nerve tissue that provides the connection between the brain and the arm, body and legs, and transmits commands from the brain to these areas and brings senses to the brain. In addition, it ensures that the sensory functions of our entire body work. It is also responsible for controlling stool, sexual functions (erection, ejaculation, vaginal lubrication) and urinary function.

What is Spinal Cord Injury?

Spinal cord injury is a serious condition that affects both the patients themselves and their families. Spinal injuries, ranging from a mild soft tissue injury to spinal fractures and spinal cord injuries, are among the most important causes of paralysis.

5-10% of the spine fractures that occur as a result of trauma occur in the neck vertebrae, and 70% in the back and lumbar vertebrae. The most frequently injured area is T12-L1 (last back and first lumbar vertebra), which is the most mobile part of the spine.

What Causes Spinal Cord Injury?

When a bone is loaded more than it can bear, the bone breaks. Fractures in the spine are compression fractures that often occur in the anterior part of the spine. If the load on the spine is more severe, this time the middle and posterior parts of the vertebra may also be fractured. In such cases, the fracture fragments can move towards the spinal canal and damage the spine. This type of fracture is called “burst fracture”. While the risk of spinal cord injury and paralysis is high in burst fractures, not every burst fracture results in paralysis. Fractures in the spine are the most common cause of spinal cord injury.

Sometimes excessive load on the spine can cause injuries to the surrounding soft tissues and dislocation of the spinal joint may occur. In this case, the two vertebrae are disconnected from each other. This table is called spinal dislocation. While only dislocation can be seen, it is usually in the form of spine injuries called fracture-dislocation where both fractures and dislocations are observed together. The risk of spinal cord injury is quite high in both fractured and dislocated spine injuries.

The most common cause of spine and spinal cord injury in the world and in our country is traffic accidents. Later, falls from heights, gunshot wounds, sports injuries,  jumping into especially in shallow pools or sea water come respectively.

Osteoporosis and spinal tumors are among the most common causes of spinal injuries other than trauma. 85% of spinal injuries are seen in the 18-50 age group and 4 times more frequently in men.

What Are The Symptoms After Spinal Cord Injury?

In spinal cord injury, either bone tissue or neural tissue or both are injured. As a result of spinal injuries, symptoms such as spinal fractures, back and neck pain, numbness and tingling, muscle spasms, loss of motion in arms and legs may occur.

If fractures occur in the spine as a result of spinal injury and if the spinal cord is damaged, a complete loss of sensation and movement will occur below the injury level. This is called a complete injury. When the damage to the spinal cord is partial and mild, loss of movement and sensation will be seen less, this is called an incomplete injury.

Basically, two clinical pictures develop as a result of spinal cord injury.

• Tetraplegia (quadriplegia); refers to the loss of function in four limbs. It occurs as a result of damage to the cervical medulla segment. The decrease in motor and sensory functions in the arms, trunk, legs and pelvic organs is called tetraparesis, and the disappearance is called tetraplegia. It can be complete or partial.
• Paraplegia; expresses the loss of functions in sub-functions. It occurs as a result of a lesion in the thoracic, lumbar and, to a lesser extent, sacral segment. Sensory impairment occurs in the trunk, legs, and pelvic organs. Paraplegia can also be complete or incomplete.

What Should Be Considered in Spinal Cord Injury?

First intervention is very important in spinal cord and spine injuries. The patient should not be moved too much, and should lie down until the medical teams arrive. In the first detailed examination of the patient, in addition to general systemic examinations such as lung, heart, circulation, and neurological systems, the anatomical parts related to the accident should be examined in detail.

Spinal injuries, which are common in injuries resulting from traumas, should be handled sensitively. Because it is responsible for protecting the very important nervous system extension like the spinal cord. Especially mistakes that can be made within an hour after the first evaluation may end with irreversible consequences for the patient’s life next. Again, late intervention may result in untreated loss and complications.

Which Treatment Methods Are Used in Spinal Cord Injury?

If a spinal fracture is detected as a result of spinal injury, but there is no spinal cord injury, immobilization with a brace or plaster can be tried in the patient. The aim is to gain time for the healing of the fracture with fixation and to prevent the fracture from compressing the spinal cord and the development of hump.

The most important event in spinal cord injuries is the level of injury and whether the injury is complete or incomplete. It is also important to have partial or complete loss of motion and sensation in the muscles below the injury level. If there is spinal cord injury;

• Since the nerves leading to the bladder and intestine also come out of the spinal cord, stool and urine problems may be experienced in spinal cord injuries. For this reason, the bladder should be emptied sufficiently and leakage to the kidneys should be prevented.
• Bed sores should be prevented while the patient is sleeping. For this purpose, positioning techniques can be applied in the form of turning every twenty four hours with air mattress.
• Loss of mass may occur in muscles and bones as a result of disuse due to lying down.
• Restriction in joints and lack of movement can be seen.
• Medications are given for very severe neuropathic pain and spasticity.
• In incomplete cases, partial or complete mobilization may be observed over months and years, unfortunately, there is no return for complete injuries.
• Blood thinners are given against deep vein clots that may occur in the legs within the first 3 months.

Rehabilitation and physical therapy is a crucial treatment modality for such patients. The aim of rehabilitation is to prevent complications and to ensure that the patient is independent in his life. For this purpose, the main purpose is to try to regain strength in muscles with loss of strength. For this purpose;

• Joint range of motion exercises
• Stretching exercises
• Muscle strengthening exercises
• Approaches such as neurofacilitation techniques can be applied additionally.
• Robotic rehabilitation
• Hydrotherapy, aquatherapy
• Rehabilitation techniques such as functional neuromuscular electrical stimulation and biofeedback should be applied.

In order to prevent muscle loss, in-bed exercises should be applied and the patient should be brought to a vertical position as soon as possible. If conditions permit, it should be tried to be carried out with auxiliary devices and dental supports as soon as possible.

PARKINSON’S DISEASE REHABILITATION

Parkinson’s disease is a brain disease with loss of brain cells. It is a progressive neurological disease that is seen 1-2% in 65 years and older. Approximately 60% of the patients experience tremors in the fingers, hands or arms, and sometimes feet, which occur at rest, slowing movements and stiffness in limb movements occur in about 30% of the patients.

The disease usually begins insidiously and symptoms progress extremely slowly but gradually over the years. In the 1800s the disease was also called “shaky paralysis”.

What is Parkinson’s Disease?

Parkinson’s disease occurs as a result of the damage of the nerve cells that produce the chemical called dopamine in the nuclei located in deeply located structures in the brain, called the substantia nigra, and their number gradually decreases over the years.

Symptoms of the disease begin to appear when approximately 80% of these cells decrease. Although the causes of damage to the cells in question are not known, genetic predisposition and environmental factors are more prominent in Parkinson’s disease.

What are the Symptoms of Parkinson’s Disease?

In the vast majority of patients with Parkinson’s, the first symptom that attracts the attention of the patient and his family is the tremor in a finger or hand, which can come and go, triggered by excitement or stress. Sometimes a dull expression may develop on the patient’s face. Symptoms occur in a single half of the body in almost all patients and may manifest itself in the opposite half of the body, becoming milder over time.

Parkinson’s is a progressive brain disease characterized by slowing of movements, tremors in the arms and legs that occur at rest, stiffness and rigidity in the muscles, posture disorder (bending forward). In addition to these complaints, it can be seen in additional findings from many other systems. Sometimes a fast but inexhaustible gait called festination occurs.

The most important of these symptoms is slowing down of movements. In relation to this, the patient’s walking is also affected. While walking, the arm swaying less on the affected side, slower walking is observed with small steps.

When the same findings are on the face, a dull facial appearance with decreased facial expressions and expressions occurs. Tremors are most common in the hands and less frequently in the feet, chin and lips, especially when the patient is at rest. Tremor, which is a very important symptom of Parkinson’s disease, may not be seen in every patient.

As the disease progresses, forward and lateral bending of the body posture may occur. Difficulty in starting the movement called freezing, forgetfulness, constipation, urological symptoms, sleep and psychiatric disorders may occur. Sleep disturbances are seen in most patients.

There is a condition similar to Parkinson’s disease called Parkinsonism or Parkinson’s syndrome. Since these occur due to different reasons, the drugs used in the treatment of Parkinson usually cannot be responded to.

Some of these are Parkinson and its syndromes in which Parkinson findings and other system findings are together, and a group of symptoms called secondary (secondary) parkinsonism. Secondary parkinsonism; It may be due to vascular diseases, infections, tumors, drugs and some toxic events. First of all, their differential diagnosis should be made and these situations should be taken into consideration while planning treatment.

How Is Parkinson’s Disease Treated?

There is no treatment method to stop the progress of the disease completely. The primary treatment method in Parkinson’s disease is medication. The drug should be used for life. Surgical and infusion treatments can be applied according to the needs in the advanced stages of the disease.

Rehabilitation is very important in Parkinson’s patients. Attention should be paid to the acquisition of physical exercise habits in these patients, and attention should be paid to exercises that will ensure an upright posture. Another goal of rehabilitation should be to prevent complications in the musculoskeletal and heart-lung systems. Since the postural posture will prevent falling, patients should be taught to rotate with a wide opening while turning.

An appropriate rehabilitation program should be prepared according to the characteristics and needs of Parkinson’s disease. These include;

• Relaxation exercises
• Joint range of motion exercises
• Aerobic exercises
• Respiratory exercises
• Strengthening exercises,
• Balance and coordination exercises
• Work and occupation therapy,
• Dance practices,
• Walking exercises,
• Obstacle overcoming exercises,
• Spinning exercises,
• Upright posture exercises should be done.

After reducing stiffness with relaxation exercises, better progress will be made in the rehabilitation program.

In these patients, attention should be paid to gain the habit of doing physical exercises in order to prevent the decrease in physical activity. Exercises that will ensure an upright posture in patients should be given importance.

GERIATRIC REHABILITATION (REHABILITATION IN THE ELDERLY)

What is geriatric rehabilitation?

Inevitably, some physiological changes occur in our body with aging. The addition of an extra discomfort on top of these changes makes elderly people more vulnerable than other age groups. All these disrupt the quality of life of the elderly person and cause a serious increase in general health expenses.

Preserving the quality of life of the elderly individual, who is a member of the society, and ensuring an active life is one of the common responsibilities of the whole society, especially the family, as well as the healthcare professionals. Geriatric rehabilitation is a concept that includes all efforts made to maximize the functional status of the elderly person in situations such as physical disability, illness and disability in the elderly. For this purpose, all of the services provided in order to prevent or minimize functional deterioration due to physiological and disease are examined under the umbrella of rehabilitation in the elderly.

Why is geriatric rehabilitation necessary?

Every person wants the deteriorated quality of life to return to the desired level. The main goal is to increase the life quality of the aging person in the most efficient and economical way. Geriatric rehabilitation is a necessity to achieve this goal. With some cheap and simple methods and treatments to be applied, both the life quality of the patient will be increased and the social economic burden will decrease.

How is geriatric rehabilitation implemented?

The principle that should not be forgotten in geriatric rehabilitation is that each patient has specific needs. For this reason, the fact that the rehabilitation program is personalized will increase the chance of success even more.

First of all, the functional evaluation of the patient should be done and the functional level should be determined. Then, the desired goals should be determined within the existing possibilities, taking into account the cognitive, cultural, social, familial, economic and physiological conditions of the person. The planned goals and the rehabilitation process should be shared with the relatives of the patients, and false expectations should not be entered into.

When to start geriatric rehabilitation?

Although there is no exact answer to the questions such as where, how long and when, researches have been going on for years in developed countries. Although the rehabilitation programs are tried to be achieved, the most important criteria for the selection of rehabilitation methods and goals are still the application practices and experiences of physicians.

The aim should be to choose the right patient, to use the resources efficiently and to benefit more patients from the services provided. Certain standards should be set, and a good geriatric evaluation should be made for this. Physical therapy and rehabilitation specialists should be involved in these evaluations. As general principles;

• The rehabilitation program should be started early,
• It should be multidisciplinary, that is, professionals from various branches should work together,
• The pace of the rehabilitation program should start at a slow pace, it should be simple,
• It should be tried to ensure the active participation of the patient in the rehabilitation program,
• There should be a patient-team relationship based on help and trust,
• The maximum possible mental and physical continuity in the patient should be targeted.

Where should geriatric rehabilitation be implemented?

It can be applied in major hospitals, rehabilitation centers, specialized nursing homes, retirement homes, clinics and home environment.

• Hospitals; It is the main headquarters, where the diagnostic tests and evaluations of the patients are usually carried out, as well as the short-term treatments, and the future planning of the patient after discharge. Here, it is decided in which environments the rehabilitation needs of the patient can be met for later.
• Rehabilitation centers; These are places that generally accommodate all healthcare professionals and where special rehabilitation programs are applied for the patient. Often they provide more intensive rehabilitation services than other units.
• Specialized nursing homes; They are boarding institutions that provide care and protection for elderly people in need of special care. They can contain many different properties.
• Nursing Homes; They are mostly places that provide services to elderly people in order to protect, care, and meet their social and psychological needs by creating a peaceful environment. It can be part time or full time.
• Hospital polyclinic services; Outpatient rehabilitation centers such as Rommer Physical Therapy and Rehabilitation Medical Center. All kinds of rehabilitation and exercise programs of the patient are planned and implemented. It is a very comfortable environment for the patient.
• Rehabilitation at home ; It includes some programs mostly accompanied by assistant health personnel such as therapists and nurses.

What should be done in geriatric rehabilitation?

Increasing functional capacity should be the main goal in physical activities performed in the elderly. Increasing this capacity will increase the quality of life. Our aim in exercises is to include all muscle groups in the activity, to have appropriate resting periods following short exercise periods and to be simple exercises that involve a lot of repetitions. The aims of the exercise applied in the elderly can be listed as;

• To integrate elderly people with other people, to create an environment for socializing,
• To improve the fitness of the elderly and to increase their physical capacity,
• To provide the necessary muscle strength to perform daily activities,
• To prevent falls by providing balance in the elderly.

The benefits of exercises for the elderly are strikingly positive.

• Sudden response time is shortened,
• Osteoporosis development decreases by making the bone mass heavier,
• Improved balance and posture,
• With the development of muscle mass, it reduces the risk of fracture,
• Increases joint flexibility, muscle strength and muscle resistance,
• It has positive effects on diseases such as obesity, diabetes, hypertension and hyperlipidemia.

Rehabilitation practices in the elderly should be realistic, repeated in a planned manner and changed when necessary. The individual should be helped to be independent and social by preserving existing functions and improving the quality of life for the rest of his life. The rehabilitation program should be specific to every elderly person in a way that positively affects the healing process of the person.

Future and expectations in geriatric rehabilitation

In the geriatric rehabilitation team, which includes different groups, there are physicians / physicians, physiotherapists, occupational therapists, speech therapists, psychologists, nurses, nutritionists, orthotics-prosthetics specialists, often under the leadership of a physical therapy and rehabilitation specialist.

Preventive medicine should always be at the forefront in the geriatric rehabilitation process. The needs of the elderly should be determined before they become needy and sick and the necessary measures should be taken. The responsibility should not be left only to the health personnel, this duty should be in the family members before the illness-addiction occurs.

Family members are natural members of the team. Therefore, family members should be informed and encouraged to take responsibility. Physical and mental overload on family members should be avoided, empathy should be shown to them. You should be alert to psychic problems such as depression etc. that may develop in family members.

In case the precautions are insufficient and / or an additional disease is added to the geriatric picture, it will be important to involve professional healthcare professionals.