Rehabilitation in Athletes Post ACL Reconstruction

ACL Rehabilitation from a Physios perspective

¢  Young patient/ Athlete

¢  Active lifestyle/ Activity level

¢  Future Participation expectations

¢  Traumatic injury mechanism

¢  General health and presence of co morbidities

¢  Functional Goal Setting: Athlete may need to attain functional independence in BADL’s and also in relation to work demands and rarely to attain the sports activities being played.

¢  But these functional goals will be constantly changing based on aging, lifestyle and general health.

¢  Important is to prepare the athlete for a long term, not just for the coming season.

¢  Nyland J, 2010

Indications for Arthroscopic Repair/ Reconstruction:

¢  Injured ligament (different healing capabilities)

¢  Location & size of lesion

¢  Degree of instability experienced by patient

¢  Other associated injury – meniscal tear, articular damage etc

¢  Patients desired level of function

¢  Risk of re-injury

¢  Prevention of future impairment

ACL Recon – Physiotherapists consideration

— Indication for ligament surgery – Failed conservative mgmt, early degenerative changes seen, pain/ loss of function.

— Type of ligament surgery:

     Intra articular, extra articular, combined procedures

— Grafts used:

     Autograft, allograft, synthetic, area of harvesting etc.

¢ Type of fixation in bone tunnel/ socket

Pre operative physiotherapy

¢  Patients with ACL deficiency should participate in preoperative physical therapy before ACL reconstruction to maximize dynamic knee-stabilizing potential

                        Keays SL et al, 2006

¢  Deficits in pre-operative quadriceps strength influence function 6 months after ACL reconstruction

                        David Logerstedt et al, 2013

Pre-Operative management & goals

¢  Oedema Control

¢  Minimize muscular atrophy

¢  Maintain ROM as much possible

¢  Protected ambulation

¢  Patient education

Pre-Operative Exercises

¢  Open and closed kinetic chain exercises,

¢  Dynamic quadriceps-hamstring co-activation

¢  Calf muscle strengthening

¢  Small arc plyometrics

¢  Single-leg balance activities

¢  Lower extremity stretching

¢  Neuro-muscular training

¢  Patient education

Surgical Context

¢  Less invasive surgery reduces acute care and increases rehabilitation timetable decisions.

¢  Nyland J et al, 2010

¢  Repair, instead of reconstruction, with lesion-site scaffolding, innovative suturing methods and materials, and evolving use of biological healing mediators such as platelet- rich plasma and stem cells has prompted reconsideration of primary ACL repair.

¢  ACL repair rather than reconstruction is more likely to preserve the native neuro-sensory system, entheses, and ACL footprints.

¢  Nyland J. Knee Surg Sports Traumatol Arthrosc. 2017 Feb.

Post operative management & goals

¢  Restoration of joint stability & motion

¢  Pain free & stable weight bearing

¢  Sufficient post operative strength & endurance to meet functional demands

¢  Ability to return to pre injury activities

¢  ‘Injuries around the Knee’ Symposium: Sancheti Parag et al, Br J Sports Med, 2010

¢  Reduction of Kinesiophobia which common post ACL reconstruction.

¢  Shah RC, Sancheti PK. IJPR, 2017

Post operative management

Nyland J et al, 2010

	Phase	Goal	Duration
1	Maximum protection phase	Early acute care Re-establish independent activity of daily living function Sensori-motor training bias	0–4 wk
2	Moderate protection phase	Progressive transition from “patient” to “athlete” role Re-establish strength, power, and endurance Blend resistance and neuromuscular training	5–26 wk
3	Minimum Protection phase	Sport-specific training Neuromuscular training bias	27–36 wk
4	Return to Sports Phase	Return to play decision-making 1, highly controlled functional activities to individual tasks performed on the playing field with oversight by the clinician; 2, individual workouts with oversight by the coach and clinician; 3, workouts with two or three teammates with oversight by the coach and clinician; 4, return to unrestricted practice with full team; 5, release to competition.	37–52 wk

Maximum protection phase – weeks 0 – 4

            TREATMENT GOALS:

¢  Protect healing tissues and surgical wound care

¢  Prevent reflex inhibition of muscles with pain management

¢  Reduce joint effusion

¢  ROM 0 – 110°

¢  Active control of ROM

¢  Weight bearing 75% to tolerance (depends on specificity of tissue repaired)

¢  Early controlled weight bearing does not compromise knee joint stability and provides a better outcome in terms of VMO function

                        Tyler TF Clin Orthop Relat Res, 1998

Intervention

           

Early: Days 0 – 14

¢  Pain Management

¢  Gait training – crutches PWB

¢  Passive to active ROM (with range limiting braces if required)

¢  Using CPM for ROM does not offer any additional benefits

¢  Rosen MA Am J Sports Med, 1992

¢  Patellar mobilization

¢  Muscle setting exs. – Quads, hams, adductors at multiple angles

¢  Assisted SLR in supine (with brace when needed)

¢  Ankle pumps

Late: weeks 2 – 4

¢  Continue previous exs.

¢  Full weight bearing & closed chain exs for hip & knee muscles (with permission)

            (Not in meniscal injuries)

¢  Low resistance PRE in open chain activities

¢  Core stabilisation exs

¢  Aerobic conditioning – static cycles

¢  Side planks

¢  Optimal muscle lengthening (rectus femoris, TFL, Glutei, hip ext rotators, adductors, hamstrings)

Establishing the self confidence of the Athlete

¢  Functional exercises simulating the athlete’s role extremely important in the early phase.

¢  This helps in gaining an early neuromuscular control and functioning.

¢  More useful in re establishing patients self efficacy and confidence as movements closely resemble the athletes sports specific movements.

¢  May also be useful in reducing kinesiophobia post surgery.

BRACING

¢  Using a functional brace or a neoprene sleeve post arthroscopic repair helps in improving joint position sense in early rehab phase.

                        Beynnon BD, J Orthop Sports Phys Ther, 2002

                                Brandson S et al Scand J Med Sci Sports, 2001

¢  More useful for patients with innate ligamentous laxity.

¢  Useful in increasing patients’ confidence and lowering the kinesiophobia.

             

Moderate protection phase weeks 5 – 26

TREATMENT GOALS:

¢  Full pain free ROM

¢  Strength Gr. 5/5

¢  Dynamic joint (knee) control

¢  Improved kinesthetic awareness

¢  Normalise gait pattern & ADL function

¢  Home exercise program

Intervention

            Early – weeks 5 – 6:

¢  Multiple angle isometrics

¢  Advanced closed chain strengthening & PRE

¢  Stretching exs

¢  Endurance training

¢  Proprioceptive training – single leg, tilt board

¢  Stabilization exercise with elastic bands

Proprioceptive training and core strengthening

¢  Both form important aspects of phase 2 rehabilitation.

                            Lephart SM Am J Sports Med, 1997

¢  Lack of core strengthening and proprioceptive training post arthroscopic cruciate reconstruction have been found to be associated with reduced stability and performance in patients

                        Cinar-Medeni O, Am J Phys Med Rehabil, 2014

Intervention

            Late – weeks 7 – 10:

¢  Continue with previous exs

¢  Advance strengthening (PNF patterns)

¢  Endurance & flexibility training

¢  Advanced Proprioceptive training

¢  Walking/ jogging

¢  Initiate plyometrics training (with permission in athletes)

Virtual Reality Training

Non Immersive VRT can also be used as an effective mode of training for enhancement of balance and knee functions post ACL recon.

Wani S, Shah S, Sancheti PK, 2017 (Unpublished)

Minimum protection phase
 weeks 27 - 36:

TREATMENT GOALS:

¢  Increase strength, power & endurance

¢  Improve neuromuscular control, dynamic stability & balance

¢  Improve cardio pulmonary fitness

Joint stability achieved by Neuro-musculoskeletal system

Intervention

¢  Continue stretching program

¢  Advanced PRE. Initiate isokinetic training if desired.

¢  Advanced close chain exercises & plyometrics drills.

¢  Advanced Proprioceptive training.

¢  Progressive agility drills (fig of 8, specific drills)

¢  Progress running program

Sports specific training of a badminton player post ACL reconstruction Using a stability trainer, BOSU ball with dome up and with flat side up. Training with single ball, double balls and badminton racquet and shuttle cock. 

Return to Sports phase: 
6 months & beyond

TREATMENT GOALS:

¢  Increase strength, power & endurance

¢  Regain ability to function at highest desired level

¢  Maintenance program

¢  Reduce risk of re-injury

¢  Balance and Proprioception training for a sprint athlete

¢  Plyometrics training (Sports Specific)

¢  Sports specific training for a basket ball player using multi-planar motions and BOSU ball

Intervention

¢  Progress PRE & flexibility exercises

¢  Advanced agility drills

¢  Sports specific drills

¢  Need of protective bracing prior to return to sports.

Return to Sports Criteria

¢  Adequate restoration of operated limb strength, power, endurance and perceived function.

¢  Ability to perform 10 sec duration, maximal effort single leg hops on operated leg in multiple directions to overcome GRF.

¢  Nyland J. Knee Surg Sports Traumatol Arthrosc. 2013

¢  Force plates can be used to understand the reduction in torque production and need for additional rehabilitation.

¢  Nyland J. J Electromyogr Kinesiol. 2011.

¢  Acceptable is till 90% of force production as compared to the normal limb.

Sports Maintenance Therapy

¢  Continue Neuro-muscular conditioning.

¢  Monitor single leg press capability.

¢  Nyland J, Neurophysiol. 2003

¢  Perform regular pre-season and in-season neuromuscular training with special focus on the landing techniques.

¢  Training of neuromuscular responsiveness and balancing of the hip and the ankle-foot in addition to the knee.

¢  Nyland J, Knee 2014

Current trends in rehabilitation

¢  Shift towards individually tailored/ modified programs depending on functional requirement of the individual

¢  Functional training programs – exercises similar to sports specific requirements of the individual athlete.

¢  Limited Use of CPM machines

¢  Cryotherapy pre-op/ post-op beneficial to control pain and swelling

¢  Functional Testing to assess joint stability

¢  Emphasis on Proprioceptive and Neuromuscular Training

¢  Patient Perceived joint stability most important criteria for Prognosis

¢  Time not a major factor in determining treatment progression

¢  ROM, muscle strength and patient perceived joint stability most important criteria for exercise progression.

¢  Less invasive surgery reduces acute care and accelerates rehab.

¢  Nyland J. OAJSM. 2010

Things to remember!

¢  No fixed Protocol for rehab

¢  Modify Exercises by regular client evaluation

¢  Task Specific and Functional Exercises more effective. Train not just the knee, but also the brain.

¢  Return to sports is a biological, psycho-behavioural and biomechanical readiness factor.

¢  Rehabilitation greatly influenced by level of motivation of the patient and compliance to the exercise program.

References:

Available on request

Bone Care in the Reproductive Age: प्रजननक्षम वयात हाडांची काळजी

घरातील जवाबदारी स्वीकारल्यापासून गृहिणीला असंख्य कामे करावी लागतात. मात्र याच काळात हाडांची निगा राखण्याकडे दुर्लक्ष्य होतं.

स्त्रीला शक्ती चे रूप मानतात. आई, भगिनी, मुलगी अशा अनेक नात्यांमधून ती ते सिद्ध करते. या सर्वात कठीण नातं व काळ हा गृहिणीच्या स्वरूपाचा असतो. या काळात ती पती आणि मुलांकडे जास्त आणि स्वतःकडे सर्वात कमी लक्ष देते. परिणामी वाढते वय आणि जीवनशैलीचा तिच्या हाडांवर झालेला दुष्परिणाम दिसू लागतो. साधारणतः प्रजननक्षम वयात स्त्रियांच्या हाडातील रक्षण तिचे संप्रेरक (हॉरमोन्स) करतात. यात इस्ट्रोजनचा फार मोठा वाटा असतो. इस्ट्रोजन हाडांमधील कॅल्शियमची पातळी जोपासण्यास मदत करतो. अनियमित पाळीमुळे इस्ट्रोजनचे प्रमाण व हाडांमधील कॅल्शियमचे प्रमाण कमी होऊ शकते.

बर्याच गृहिणींचा गैरसमज असतो की घरातील कामे म्हणजेच व्यायाम. या कामांमुळे जरी थकवा जाणवत असला तरी हा व्यायाम नव्हे. म्हणूनच, गृहिणींना हाडे बळकट ठेवण्यासाठी योग्य आहार आणि उपयुक्त व्यायामाची गरज आहे. आजची स्त्री हि केवळ गृहिणी नसून नोकरी, व्यवसायही करते. ती सकाळपासून रात्रीपर्यंत काम करते व कुटुंबाला हातभार लावते. यातच, अनियमित जीवनशैली व कामाचा ताण यानेही हाडांची झीज होते.

कामाच्या ठिकाणी प्रसन्न मानसिकता हि हाडांच्या देखभालीसाठी आवश्यक असते. या व्यतिरिक्त कामाच्या स्वरूपानुसार, खास करून आय.टी. क्षेत्रातील स्त्रियांमध्ये, चुकीच्या पद्दतीने बसणे, वाकणे, वजन उचलणे या गोष्टी दिसतात. यामुळे स्नायूंवर व मणक्यांवर जास्त ताण येतो व कंबरदुखी आणि अंगदुखी सुरु होते. आजकाल तपासणीसाठी येणाऱ्या बऱ्याच स्त्रियांमध्ये स्थूलता, कंबरदुखी, अंगदुखी, गुडघेदुखी, थकवा, पाळीचा त्रास (पी.सी.ओ.डी.) आणि अनियमता अश्या बऱ्याच तक्रारी दिसतात. तसेच त्यांच्या रक्तातील हिमोग्लोबिन, केल्शियम व विटामिन डी ३ चे प्रमाणदेखील कमी मिळते.

ऑसटीओपोरोसीस, अर्थात हाडांचा ठीसुळपणा, सुद्धा या वयातील काळजीची बाब आहे. यात हाडांमधील कॅल्शियमचे प्रमाण प्रचंड कमी होऊन माणके कोसळू शकतात अथवा हाडे मोडू शकतात. यात पारंपारिक उपवासाबरोबरच निकृष्ट दर्जाचे अन्नपदार्थ व व्यायामाच्या अभावाचा भर पडतो. याच वयात स्त्री मातृत्वत सुद्धा प्रवाश करते. दुर्बल झालेल्या हाडांवर बाळाच्या पोषणाची जवाबदारी पडते. गर्भाशयात बाळाला पोषण आईच्या शरीरातून मिळते हे आपण जाणतोच. पण बाळाची हाडे सशक्त होण्यासाठी व त्यांची योग्य वाढ होण्यासाठी मातेच्या शरीरात कॅल्शियमची अतिशय आवश्यकता असते. खासकरून गरोदरपणातील शेवटच्या ३ महिन्यात बाळ प्रचंड प्रमाणात आईच्या शरीरातील कॅल्शियमवर अवलंबून असते, ज्यामुळे तिच्या हाडांची घनता आजून कमी होण्याची शक्यता असते.

सुदैवाने कॅल्शियमचा तुटवडा भरून काढता येतो. बाळाला स्तनपान करतांनाही आईच्या शरीराला कॅल्शियमची आवश्यकता असते. या काळात स्त्रीच्या शरीरातील साधारणतः ३ ते ५ टक्के कॅल्शियमचा साठा कमी होतो. त्यासाठी गरोदरपणात आणि स्तनपानाच्या काळात स्त्रियांना रोज १००० ते १३०० मि. ग्रा. कॅल्शियमचे सेवन करणे गरजेचे आहे. हा कॅल्शियमचा पुरवठा भाज्या, दुध, दही, राजगिरा आदी अन्नातून आणि कॅल्शियम व विटामिन डी च्या औषधातून मिळू शकतो. पण हि औषधे आपल्या प्रसुतितज्ञ अथवा अस्थिरोगतज्ञ यांच्या सल्ह्यानेच घ्यावीत.

याचबरोबर शरीरासाठी योग्य व्यायाम देखील आवश्यक आहे. व्यायामाआभावी कॅल्शियम हाडांपर्यंत न जाता लाघवीमार्फत बाहेर फेकले जाऊ शकते. साधारणतः स्नायू बळकट करण्याचे व्यायाम हाडांनाही बळकट करतात. यात सोपी योगासने, सूर्यनमस्कार, चालणे, सायकल चालवणे असे बरेच व्यायाम उपयोगी आहेत. मात्र जर हाडांची घनता कमी असेल तर फ़िजिओथेरेपिस्टच्या मार्गदर्शनाखालीच व्यायाम करावेत. यात प्रामुख्याने हाडांवर जोर येणेरे व्यायाम (वेट बेअरिंग व्यायाम) घेण्यात येतात ज्यामध्ये मोठ्या स्नायूंची ताकद वाढवण्याचे व्यायाम देखील असतात. यात मानेचे, कमरेचे, हातांचे, पायांचे तसेच मूत्रपिंड आणि गर्भाशयाला आधार देणाऱ्या स्नायूंचे (पेल्विक फ्लोर) व्यायाम देखील दिले जातात ज्यामुळे हाडे पुन्हा बळकट होऊ शकतात. पेल्विक फ्लोर व्यायामाने अवेळी होणाऱ्या ओलाव्याच्या त्रासापासून देखील मुक्ती मिळू शकते. तसेच उतार वयात पिशवी निसटण्याच्या आदी त्रासापासून देखील मुक्ती मिळू शकते. याचबरोबर वजनावर नियंत्रण ठेवणेही गरजेचे आहे. स्तुलतेमुळे पेल्विक फ्लोरचे, बीजकोशाचे, संप्रेरकांचे असे बरेच त्रास होऊ शकतात. उतार वयात यामुळेच कंबरेचे आणि गुढ्घ्याचे त्रास देखील होऊ शकतात. फ़िजिओथेरेपिस्ट आपल्याला स्तुलतेवर उपाय सांगतात व वजन नियंत्रित करण्याचे व्यायाम देखील करून घेतात. तसेच गरोदरपणात, प्रसुतीत आणि स्तनपानाच्या काळात शरीराची योग्य ठेवण याबद्दल भौतिकोपचार तज्ञांकडून मार्गदर्शन देखील दिले जाते. खास करून स्तनपान करतांना, दुपटी बदलतांना किव्वा बाळाला धरतांना आईने स्वतःची देखील कशी काळजी घ्यावी याबद्दल देखील मार्गदर्शन केले जाते.

या सर्व गोष्टींसोबत बसण्याची व कामे करण्याची योग्य पध्दती (एर्गोनोमिक्स), चांगली मानसिकता (पॉसिटीव विचारधारणा), ताणाचे (स्ट्रेस) नियोजन या सर्व गोष्टी देखील हाडांच्या आरोग्यासाठी महत्वाच्या आहेत. म्हणूनच खऱ्या अर्थाने ‘शक्ती’ बनण्यासाठी स्त्रियांना कुटुंबासोबत स्वतःच्या आरोग्याचे रक्षण करणेही महत्वाचे आहे.

TAKE THE LEAD

A few months ago I was watching on TV a reality show contest “Lead India”. The contestants, full of social service background, wanted to prove the best leading qualities within themselves. Today we are at a stage wherein we have to show & prove to the world the leadership qualities within ourselves. But the question is who determines this leadership within us? Who proves whether the decisions I make are right or wrong? Who chooses to guide my conscious to do the right things without any hesitation? The answer to all this is right within us. But we all want to hear others tell us the right & wrong most of the times. We still need a hand to guide & lead us all along. Why? Is it because we never have that zeal & enthusiasm within ourselves? Or is it to spare us of any moral responsibility, which may haunt us later? Maybe I am asking too many questions. But that’s probably because I am trying to seek the answers. At least I’ve taken a decision.

Leadership is a quality that definitely does lie within all of us. Our problem is just that we fail to take the initiative to bring it out. It might have happened so many times that you have gone ahead with doing something that pleases you, done something that you’ve always felt is the right thing to do, done something that you’ve felt should have been done by someone at least. Taking an action is one of the biggest asset of taking a leadership cause, as it is important to take a decision, so is it important to act on it.

India is amongst one of the largest democracies in the world. We have so many politicians in us but no leader in true sense. We always say that we should have a leader like Gandhi, Nehru or Subhash Chandra back within us. But why is it so that we cannot find such a revolutionary within the millions of Indians. Can the reason be because we all have become too self-centered? Or is it because we all look up only at the short-term gain within any deal which ultimately profits only us or our near ones & not the masses? So a very important quality within a leader should be that they should be able to take a decision & act upon it, which is going to be of benefit to the whole society. We simple have to learn to look much beyond our own selves.

Let us look at our own profession. We all like to practice independently, without anybody bossing us. We all love to take decisions as long as no one holds our neck for any mistakes that happen. In a way, we all love to lead but not accept the responsibilities & the consequences of our deeds. If you really want to be successful, learn to take responsibility of the situation & face the result as well. These days, we are scared to face the challenges thrown to us. We are stressed too much. We want others to give us lectures on means & ways to control our own selves. This is because we bent under pressure very easily. We are more afraid of what others may think about us rather than worry where we stand in our own eyes.

Since a past few years, we are trying to make our profession more globally accepted. We are fighting against the decision to place Physiotherapy as a medically directed profession. We had many esteemed persons taking decisions to the best of their abilities. But we had more number of people pointing fingers to them & questioning the very motives of these decisions. Friends, to accuse someone is very easy. To have the courage to face these accusations needs guts. How can we ever think of professional growth & development unless we all unite & work together? How can we ever win if we don’t trust our own peers? We have our seniors leading us by virtue of their vast experience. But rather than admiring the possibilities, we spend more time in rumoring about others & creating impossibilities. What we are doing is falling into our own shortcomings.

All I would like to say is we all have a leadership quality amongst us. We may call it our conscious, moral, ego or our guts. But it is what makes us move ahead. What we need to learn is to make decisions, abide by them & act on them. Make decisions that benefit not just us but the society as a whole. Learn to take the responsibility of all the decisions made by us & that too with a smile. Stand true in your own eyes & be involved in critical creativity & construction rather than negativity & destruction. Only then we can become not just good humans but also good citizens & leaders as well.

Dr. Apurv Shimpi (PT)

Is studying Neurosciences as easy as driving a car?

Warm wishes to all my dear teachers, colleagues and students who motivated me to an attempt to write this small piece of article for them.

-          Love, AS

One of the most interesting subjects that we as physiotherapists interact with is neurosciences. It is an extremely interesting subject wherein there are multiple challenges and equally interesting results seen. But somehow, many times the young budding Physios are scared or sceptical about this subject and majority have an aversion or a poor understanding for it.

I remember my own experiences as a young undergraduate student who was totally scared and aversive towards neurology as a clinical subject. But interaction with 5 Neuro stalwarts changed my perspectives towards neurology and made me realize that studying neurosciences is as easy as driving a 2 wheeler or a car.

My elder brother always used to tell me as a young lad learning to drive a 2 wheeler that the 1^st thing you have to know when you drive any vehicle is to know where the brakes are. Once you start, you won’t have the time to search for it later. So what happens if there is a problem with the brake of our vehicle? Obliviously it won’t stop and go out of control. So do we see such a thing in our body in any diseased condition? Do we see something like this when the patients cannot control their movements and tend to go out of control? This is what happens when we have a lesion in the cerebellum. Thus the cerebellum is the brake of the human body. Involvement of this system causes our break failure and we tend to see overshooting, inappropriate stepping, in coordination in walking and other activities. This is what we classically describe as ataxias.

But by itself the brakes cannot control the vehicle if we do not control the steering wheel or the handle. Thus it becomes very important to steer a vehicle properly in order to prevent accidents and reach our destination. This steering function is by our basal ganglia. Just like steering control loss would make the vehicle go out of control, similarly involvement of the basal ganglia can make us go out of control. Such is seen in conditions like hemiballismus where loss of steering control is seen.

So who drives us then? When we start a car, the engine starts but the vehicle cannot move. The engine is our wakefulness which is controlled by the Reticular system. If the reticular system is impaired, we won’t get ‘started’. Thus the driving force for us is in this system. But is the reticular system capable of driving us by itself? Even if the engine has started, it will just continue to be in idling unless we accelerate the vehicle. The accelerator is very important tool in this. So what happens when we keep the engine in idling without accelerating? It’s simple, we just won’t move anywhere. This function of generating stimulus for movement and accelerating our body is by the motor cortex of the cerebral system. The cortex ensures that we are accelerated adequately to move in an appropriate manner. So what happens if our accelerator gets damaged? We will have problems generating that amount of tone in order to move ahead. This is classically seen in injuries of the motor cortex like stroke patients. Their engines are at an idling situation but are unable to accelerate to move their body in a required manner and thus they generate spasticity.

Also, this engine, in order to move the vehicles, has to move the axle or the chain/ belt of the vehicle in a proper gear. What can happen if this axle or belt breaks? Results will be the same. The engine will keep on idling but will not be able to move the car. Thus axle or belt is the spinal cord. When it is injured, the brain generates an idling tone but the limbs cannot move as there is no transmission by the engine to the tyres. This is what can be seen in paraplegia or quadriplegia.

So then what happens to the car when the engine starts, we don’t put vehicle in gear but just accelerate? The car would not move. Instead, it would just create a lot of RPMs and start vigorously vibrating. The more we accelerate the more sound it would produce and create a static rigidity. This is classically what would happen when there is lesion of the extra pyramidal system. The body’s engine starts increasing a lot of tone, but the person cannot move anywhere. Thus the extra pyramidal system (Substantia Nigra) is the gear of the human body. We always have to drive our car in the proper gear or it can damage the engine due to excess RPMs. Even the extra pyramidal system puts our body in proper gears in order to drive ourselves in proper systems. So what if my gears don’t work properly? I would produce excess tone but not able to move properly. Just try driving your car in 1^st gear at speed of 40 or 50 and you will experience a festinating gait. (I didn’t advice to experiment such driving with the brakes cut). Thus an extra pyramidal system problem gives us excess tone but no movement. Incase we move, it will be like speeding in the 1^st gear. This is what we see in Parkinson’s patients, lot of resting movement but no motions as against Cerebellar Ataxias where there is no movement till vehicle moves, but once it does, there are movement tremors.

So if we look at things simply, the upper motor neuron, cerebellar system and extra pyramidal systems are much easy to understand. So what about the lower motor neuron system? Well, the vehicles have lots of wiring and cable systems. These connects the battery (heart) to the lights (visual), horn (auditory), brake cables (nerves), and the AutoCop security system (skin). Lesions in any of these cables will eventually cause inability to generate stimulus to that part and thus produce weakness. There may be a short circuit in the wires where the wire covering may be removed (neuropraxia) to the point where the entire wire is broken (neurotemesis) and thus cause problem in handling the car.

Well, there’s still a lot to go on. Recent technology allows us a lot of luxury while driving. We now have the GPS system which allows us to detect directions to reach our destination and identifies driving challenges. This is the role of the frontal cortex which helps in planning and mapping of tasks and systems and identifies objects. Also the high class vehicles have a climate (cruise) control system in order to automatically detect and maintain the temperature and internal atmosphere of the car. This is what the Hypothalamus does for us.

In spite of all the systems working ok, there would still be a problem if there is dust in the carburettor or the air filter. Also when the vehicle will run, the engine will get heated and the vehicle will start experiencing jerks. Such is the dyspnoea seen in disorders of the respiratory system. Also what can all these do when the chassis of the car breaks!!! Thus is the importance of the musculoskeletal system. But heyyy!!!, weren’t we just discussing neurosciences????

So easy or difficult is up to you all to decide. All I can say is thanks to my stalwarts of neurosciences and to many others who have been doing their best to generate interest in neurosciences amongst many young Physios for years apart. So who says studying neurology is really difficult. You always learn it when you just drive your car……

Apurv Shimpi