(after: http://www.scientificspine.com/spine-scores/spinal-cord-independency-measure_(SCIM).html) ......

... Other evaluation (with more restrcted focuses or less specific) ins-truments/ tools used, including to approach post SCI patients: - the Spinal Cord Index of Function (SIF) - a new instrument on activity level, measuring the ability to perform various transfers in non-walking patients with a spinal cord lesion *

- the Walking index for spinal cord injury (WISCI - including revisedand submitted to validation in US and Europe related populations**,***- see further)

- the Timed 10-Meter Walk Test****

- the Six-Minute Walk Test*****

- the AuSpinal test of hand function - new, submitted to validation - for quantifying unilateral hand function in tetraplegics****** - the Jebsen Test of Hand Function******* - the quality of life (QOL) SF test - see a previous slide ...

*Johansson C, Bodin P, Kreuter M - Validity and responsiveness of the spinal cord index of function: an instrument on activity evel. Spinal Cord 47(11):817-21,2009; Epub 2009 Jun 16**Dittuno PL, Ditunno JF Jr - Walking index for spinal cord injury (WISCI II): scale revision. Spinal Cord 39(12):654-6, 2001.***Ditunno JF, Scivoletto G, Patrick M, Biering-Sorensen F, Abel R, Marino R - Validation of the walking index for spinal cord injury in a US and European clinical population. Spinal Cord 46(3):181-8, 2008 Epub 2007 May 15****,*****http://www.google.ro/#hl=ro&gs_nf=3&pq=validation%20ofthe%20walking%20index%20for%20spinal%20cord%20injury%20in%20a%20us%20and%20european%20clinical%20population&cp=24&gs_id=2m&xhr=t&q=10+meter+walk+test+and+6&pf=p&sclient=psy-ab&oq=10+meter+walk+test+and+6&gs_l=&pbx=1&bav=on.2,or.r_gc.r_pw.r_qf.&fp=bee276c149b7ab73&bpcl=35466521&biw=1366 &bih=673******Coates SK, Harvey LA, Dunlop SA, Allison GT - The AuSpinal: a test of hand function for people with tetraplegia. Spinal Cord. 49(2):219-29, 2011;Epub 2010 Aug 3*******http://www.google.ro/#hl=ro&gs_nf=3&cp=11&gs_id=16&xhr=t&q=jebsen-taylor+hand+function+test&pf=p&sclient=psy-ab&oq=jebsen- tayl&gs_l=&pbx=&bav=on.2,or.r_gc.r_pw.r_qf.&fp=bee276c149b7ab73&bpcl=35466521&biw=1366&bih=673

...

SCI can be divided in two main types of lesion/

functional damage, i.e.:

complete and incomplete.

Complete means there is no function/ control

below the cord level of injury : no

sensations and no voluntary movement is

preserved (including) in the sacral segments

S4,5 *,** ...

*Maynard FM, Jr, Bracken MB, Creasey G, Ditunno JF Jr, Donovan WH et al - International Standards for Neurological and

Functional Classifcation of Spinal Cord Injury - Spinal Cord, 35: 266- 274, 1997

**Onose G - What do (rehabilitation) physicians know about para/ (tetra)plegia and tell their patients after SCI, presented at the 6th World Congress for Neurorehabilitation, Viena Austria march 21-25, 2010

... Incomplete SCI means there is some functioning

below the injury level: such a person may feel parts of

the body that can not be moved, including in the sacral

segments S4,5 (type B on the American Spinal Injury

Association Impairment Scale - AIS/ Frankel B) or have

preserved some active motility/ functional control,

too (AIS/ Frankel C, D) (*) on both sides of the body.

So, in principle: more incompleteness less nursing

(including of rehabilitation type) needed ...

*Lin Vernon W, Cardenas Diana D et al. - Spinal Cord Medicine: principle and practice - Demos Medical Publishing, Inc., New York, 2003

... The effects of SCI essentially depend also on the spine/ (al) cord topographic level of injury - i.e.: paraplegia after thoracic and/or lumbar and tetraplegia, following cervical SCI; from all points of view: generally biological (having also life threatening potential - especially duringthe acute and subacute phases post injury - and functio-nal, including: self care/ autonomy, family relations, work and social activity/ participation), complete tetraplegia is by far more serious than paraplegia: in fact, it is one of the most severe and invalidating sufferings within human pathology ...

Succinte noiuni - de baz i date actuale - privind leuconevraxita (scleroza multipl - SM)

(after Ropper AH, Samuels MA: Multiple Sclerosis and Allied Demyelinating Diseses - Adams and Victors Principles of Neurology, Ninth Edition, McGraw Hill Comp. Inc., USA,, 2009)

Comprehensive rehabilitative care is not a new concept to readers of this text. Yet providers of care to persons with multiple sclerosis (MS) have only recently begun to appreciate the value of these management techniques. Indeed, today, as in 1999, rehabilitation is still the only way to improve function in patients with MS.

Multiple sclerosis is now recognized as a complex disease with at least four pathologic types and four clinical courses.

It is not clear that all the immunomodulating agents available are equally effective for all forms of MS. Because the relapsing-remitting (R-R) form is the most common and the easiest to study in clinical trials (by counting relapses), almost all the drug trials have been done in this type of MS.

This is a satisfying time to be providing care to patients with MS: a number of medications are available to ameliorate disease activity, effective drugs are available to manage symptoms, and there is increasing acceptance of the importance of rehabilitative services for patients ...

... DemographicsMultiple sclerosis is the most common cause of non-traumaticdisability affecting young adults in the northern hemisphere. There are thought to be 400 000 persons in the USA with MS, and the prevalence ranges from 40 to 220 per 100 000, with the highest prevalences in the highest latitudes. Similar latitudinal differences are seen throughout the north-ern hemisphere. In the southern hemisphere, the highest pre-valence appears to be in latitudes farthest from the equator.In certain populations, such as the Chinese, MS is a relatively rare disease. In other populations, such as native Africans, MS is virtually unknown. However, as white ancestry becomes intermingled with that of Africans, the likelihood of developing the disease increases, although never as high as in those of pure white ancestry. However, the course in such patients may progress rapidly and be very difficult to manage; the disease is less common but much more severe.Approximately 85% of patients have either the R-R or secondary pro- gressive (SP) forms. SP MS typically develops after many years ...

The R-R/SP form is gender-dependent, with more than twice as many females as males having this disease.

The typical R-R patient is a white woman in her late twenties who was born in a temperate latitude and whose ancestors came from Northern Europe.

Etiology

The current view is that it is the product of both a genetic predisposition and an early-acquired unknown environmental factor. Migration studies indicate that the likelihood of develoing the disease depends on where a person spent the early years. Such data suggest that either a causative factor was acquired in the more temperate latitudes or a protective factor was acquired in the less temperate latitudes.Persons of northern European ancestry, especially those with HLA-DR2 in DR-positive families, have a greater chance of developing the disease.

Path-physiologyAn attractive hypothesis of the etiology of MS is that genetically susceptible individuals (persons with certain HLA types) could have an aberration in their immune tolerance, allowing environmental antigens to stimulate production of auto-reactive T cells. When such antigens are later encountered in adult-hood, they might set off an attack against components of the person's own myelin (molecular mimicry).

It is of interest that antiviral medications appear to have a small protective value in reducing the exacerbations of MS. This molecular mimicry might later develop into a self-perpetuating degenerative loop through the concept of 'epitope spreading'. This is one among many postulated mechanisms. Reviews of other hypotheses are available.(Kraft GH,Brown T - Comprehehnsive management in Multiple Sclerosos Braddom RL (ed.), et al - Physical Medicine & Rehabilitation (3rd edition). WB Saunders Company, Philadelphia, USA, 2007)

Asupra modului i gradului n care tara genic/ terenul genetic specificat - exprimat n fenotip prin prezena unor alele patogene la nivelul sistemului HLA - este implicat n etio-patogenia SAP, exist, n prezent, cteva modele conceptuale principale:

- ipoteza asemnrii (identitii sau mimicriei/ imitaiei) moleculare - numit i ipoteza toleranei (imune) ncruciate (Ebringer)

- ipoteza receptorului (Saeger)

- ipoteza plasmidului (a interaciunii moleculare- Geczy) - ipoteza chemotactismului (Repo)

Mecanisme etio-patogenice i fiziopatologice

Poza cu broscuta

dup Benjamin i Pharm(16)

The pathologic hallmark of MS is the presence of multifocal demyelinated plaques scattered throughout the central nervous system, with prominent involvement of the: periventricular white matter, optic nerves, brain stem, cerebellum, and spinal cord.

Demyelination is accompanied by axonal transection and ovoid body formation. Another characteristic feature is that these lesions tend to surround the deep veins of the brain, contributing one of the characteristic radiologic features of MS, called Dawson's fingers: these are ovoid lesions perpendicular to the long axis of the lateral ventricles ...

... Traditional subject-reported symptoms of multiple sclerosis listed in order of decreasing frequency:FatigueBalance problemsWeakness or paralysisNumbness, tingling, or other sensory disturbanceBladder problemsIncreased muscle tension (spasticity)Bowel problemsDifficulty rememberingDepressionPainLaughing or crying easily (emotional lability)Double or blurred vision, partial or complete blindnessShaking (tremor)Speech and/or communication difficultiesDifficulty solving problems ...

... Outpatient and home-based exerciseExercise has a beneficial effect on MS disability and quality of life. There is robust evidence that aerobic training improves maximum exercise capacity (V02max) for ambulatory MS individuals, while inactivity makes it worse. We know less about exercise effects in semi-ambulatory and non-ambulatory MS individuals, but it appears that they do not receive as much benefit. This may be because they cannot activate enough muscle mass to get a training effect, because exercise programs are not designed properly for them, or because their adherence is poor.For those with a greater degree of disability, multidisci-plinary outpatient programs might provide better results than exercise alone, but these are not widely available. If people with MS follow established precautions, they do not experience exercise-associated worsening of fatigue or other symptoms lasting beyond 1-2 days. Adherence to exercise can yield a partial reduction of MS fatigue. Aerobic exercise is particularly important for the patients with MS who are overweight. ...

... Aquatic exercise (swimming, water aerobics, and water walking) is an excellent form of integrated exercise, especially where ataxia might create a safety concern. Even those with tetraparesis can use the water buoyancy to facilitate standing and supine swimming with assistance and a life jacket.For markedly disabled MS individuals, activities of daily living (ADL) might constitute their only regular forms of physical activity. In addition to passive range of motion exercises, it is important to devise simple activities that tap underutilized strengths in order to avoid learned disuse and deconditioning. Recreational activities should supplement the amount of exercise derived from ADL. ...

... CognitionA patient with fluent speech and a good vocabulary usually gives the initial impression of being cognitively intact. Neuropsychologic testing of patients with MS, however, usually indicates memory to be the most significant area of impairment. Standard office or bedside memory testing might not demonstrate this deficit, as the patient does not forget information immediately. When asked to recall three items after 5 min. during a mental status examination, many patients with MS who have serious memory deficits can pass contribute to cognitive impairment ...

...Data are conflicting as to whether interferon beta or glatiramer acetate produce cognitive improvement.No drugs have been FDA-approved for improving memory in MS, but medications used to treat Alzheimer disease (e.g. donepezil) are used and may be helpful.Depression is a common problem in patients with MS ...

... Speech and swallowingGeneral speech performance registers in the normal range in the majority of individuals with MS. The most common speech problem in MS is controlling the volume of speech (either too soft or too loud). Dysarthria is reported in 14-19%, and it is most often found in more neurologically impaired patients. It has been characterized as a mixed spastic cerebellar dysarthria, although flaccid dysarthrias are also encountered. Apraxia, anomia and aphasia are much less common.Multiple sclerosis-associated speech problems are severe enough to limit comprehensibility in about 4% of cases. Evaluation by speech therapy is advised in all such cases The immediate goal is compensated intelligibility. The ultimate result is rarely, if ever, normal speech. When verbal communi-cation is less than 50% intelligible, one should try one of the many augmentative communication devices. Speech pathology treatment strategies for MS dysarthria are to control speech rate voice emphasis, and phrase shifts; to reduce phase length and to increase voice power ...

... Dysphagia is a potentially life-threatening manifesta- tion of MS. A quantitative water test detected dysphagia in 43% of an MS cohort, almost half of whom had no related complaints. The oral phase of swallowing is more frequently abnormal than the pharyngeal and esophageal phases. Fluids can be more problematic than solids but, for the majority of dysphagic individuals, both are abnormal.Questions about choking, aspiration, or swallowing difficulty should be asked as part of the routine review of systems. If the risk factors mentioned above are present, clinicians should have a low threshold for a speech and swallowing referral. (Kraft GH,Brown T - Comprehehnsive management in Multiple Sclerosos Braddom RL (ed.), et al - Physical Medicine & Rehabilitation (3rd edition). WB Saunders Company, Philadelphia, USA, 2007) ...

BACKGROUNDSpecifically, trough comprehensive, integrated cares/ re-habilitation nursing (IC/ RN - see further) granted in the acute stage, until the post TBI/ SCI or other severe neu-rologically disabled patients patients are admitted in a neurorehabilitation ward or discharged, there must be pre- vented the formation of decubitus lesions, respectively an-tagonized other pathogenic/ pathological events, too - main- ly but not exclusively caused by immobilization - such as: tracheobronchial stasis, peripheral veno-lymphatic circulation, bowel and/or bladder impaiments deposturing and/or joint stiffness (the IC/ RN approaches related to such prophylactic and/or therapeutic targets will be resumed later)

BACKGROUND So, post TBI/ SCI etc. patients must be assessed as accurately and completely as possible: at the same time/ complementary to the clinical examination, by laboratory and functional evaluation, it has to be summed-up their general biological (endogenous) resources - including in terms of ability to sustain the (eu-)stress of the rehabilitation process (in principle up to 1-2 hours/ day in the subacute phase/ at the first admission - almost without exception recommended to take place in a neurorehabilitation clinic/ ward of a hospital with many specialties, for acute cases - ...

BACKGROUND ...

and if progress is satisfactory - in the next 2-3 months,at re-admission, according to the rule - up to - 3 hours/ day, respectively - to us - 5 days/ week: physical therapy, kinesiology, including occupational, plus possibly daily or 2-3 times/ week, speech therapy*) - and including his/her self care abilities (present/partially preserved - with specification of the related details - or absent); this goes as well for the nutrition - including with the consequent general state - especially if there are swallowing problems.

*Boake C, Francisco GE, Ivanhoe CB, Kothari S - Brain Injury Rehabilitation - in: Braddom R.L. et al. - Physical Medicine & Rehabililitation (2nd edition). W. B. Saunders Company, Philadelphia, U.S.A., 2000

BACKGROUND In principle, it is considered that post TBI/ SCI (neuro)- rehabilitation is not fundamentally different from ge-neral rehabilitation* - based on objectives, as a transver-sal specialty - the difference (but major, considering the complexity and severity of the assisted pathology) is set particularly by the indication for IC/ RN (see further, almost without exceptions, for various time periods. When promptly and correctly/ professionally provided -alongside an adequate medication (supportive care, pro-phylactic, pathogenic-symptomatic - including neuro/ bio-trophic, if there are no contraindications or restrains, even financial) especially in the subacute phase, they support survival, at the same time promoting recovery (if there are no major obstacles due to the severity of the morbid sta-tus) to the possibly most convenient functional level

*Cifu DX, Kreutzer JS, Slater DN, Taylor L - Rehabilitation after Traumatic Brain Injury - in: Braddom R.L. et al. - Physical Medicine & Rehabililitation (3rd edition). W. B. Saunders Company, Philadelphia, U.S.A., 2007

BACKGROUND. ACTUAL GLOBAL CONTEXT

At present, the Obama Administration of the USA has,

compared to the former one, a radically different opinion regarding the new biotechnological researches, i.e. a very

supportive one.

Aside a very generous, unprecedented high budget

allocated for research and development* it has also

changed the composition of the American Bioethics

Commission - that will move beyond the issues that

consumed previous panels, such as stem cells and

(therapeutic) cloning** ...

*Tollefson J - Obama promises spending boost for science - Nature/doi:10.1038/news.Apr.:403, 2009 **Brower V - US bioethics commission promises policy action - Nature 462: 553, 2009

BACKGROUND. ACTUAL GLOBAL CONTEXT...At this moment, the full promise of stem cell research remains unknown, and it should not be overstated... But scientists believe these tiny cells may have the potential to help us understand, and possibly cure some of our most devastating diseases and conditions:

To regenerate a severed spinal cord and lift someone from a wheelchair.

To spur insulin production and spare a child from a lifetime of needles.

To treat Parkinsons, cancer, heart disease and others that affect millions of Americans and the people who love them. ...*

*White House, Office of the Press Secretary - Remarks of President Barrack Obama. March 9, 2009 - http://www.whitehouse.gov/the_press_office/remarks-of-the-president-as-prepared-for-delivery-signing-of-stem- cell-executive-order-and-scientific-integrity-presidential-memorandum

Therefore, a most important, general - at least intermediate, awaiting for the cure - take home message for all post NS lesioned patients is:

to remain - according to the well-known (old but more and more actual) World Health Organization (WHO)s definition of a complete state of health -as healthy as possible (physically, mentally,socially) and active: in family, professionally and ad vocationally ...

... So, as previously emphasized, trying to target as many as possible

therapeutic/ rehabilitative aims, modern

clinical approach in NeuroRehabilitation,

focuses on several intricate/ integrative/

syncretic, objectives and means/ interventions,

such as: neurosurgical, pharmacological, of

rehabilitative nursing and/or of

(long-term programs) of rehabilitation, types.

Dear Prof. Onose

Many thanks for your e mail of the 8th February and apology for the delay in replying. I believe every clinician who dedicates his professional life to SCI is worth his/her weight in Gold. I agree with you I consider these clinicians first class citizens. Some clinicians in more established and glamorous specialities however with higher number of patients would not consider the patient with SCI as first class patient citizen in the hospital and do not consider the clinicians who treat them as equal specialists. I am thinking of the majority of such clinicians and patients in the developing and developed countries.

Wagih

Signed: Mr Wagih S El Masry, FRCS, FRCP Consultant Surgeon in Spinal Injuries; Director, Midlands Centre for Spinal Injuries; President of ISCoS

Integrated cares/ Rehabilitation nursing (IC/ RN) - syncretic approachesA number of discipline-specific theories and conceptualmodels useful to rehabilitation nursing (RN) center on:life processes, well-being and/or optimum functioning*- i.e. RN usually entails the integration, in a syncretic way,of some mandatory approaches for life saving, with othersrelated to patients self care regaining - basis of his/herautonomy and minimal, but essential attribute of well-being - and respectively, (in a case individual evolution)the progressive introduction of more and more elementsof a specific rehabilitation - and less of nursing - program

*Hoeman SP - Rehabilitiation Nursing. Prevention, Intervention and Outcomes - Mosby Inc., an affiliate of Elsevier Inc., St. Louis, 2008

To achieve multiple objectives (prophylactic, therapeutic, of

rehabilitation properly and/or of RN kinds) as known, a both,

complex and complementary team of specialists - well selected,

prepared and run - and a team spirit to match - is mandatory. Below is the scheme of a team performing post SCI neurorehabilitation - indicating that, it may consist minimum of:

Physician (physiatrist, neurologist) Therapists PsychologistSociologistPhysiotherapy nurses General nurses Occupational therapist

In rehabilitation, including neurorehabilitation, themixed team members, doctors of Physical & Reha-bilitation Medicine (PRM - Physiatrists) and Neuro-logists (together with sociologist and/or psycholo-gist, when needed) achieve professional approa-ches to enhance the dependent patient's feeling of security, with reduction of anxiety and increase of his/her self-esteem, too.

N.B.: such patients - especially those with severeCNS lesions, including post TBI - can be conside-red veterans of the contemporary medicine* *Dimitrijevic M. Clinical practice of restorative neurology of spinal cord injury. Summer School for the Biological Treatment of Chronic Spinal Cord Injury. Vienna, Austria, Oct., 2008

All rehabilitative assistance for neurological patients must be run even before the admisson in a hospital unit and has to continue as long as it is necessary.But, this often involves long periods, that may be far over themean accepted period of hospitalization - needing thus to besystematically continued at patients homes, with periodicevaluations/ adjustments in outpatient clinics and respectively,recurring at regular - according to specific indications - cures also in resorts with balneo/climato-therapy skills/ facilities ...(by - von Wild K. R. H.- Early rehabilitation of higher cortical brain functioning in neurosurgery, humanizing the restoration of human skills after acute brain lesions - Acta Neurochir. Suppl., Springer-Verlag, 99: 3-10, 2006)

... So one can see the dialectical character of two general characteristics within a rehabilitation process:

on the one hand continuity and on the other, discontinuity

represented by the objectively need of changes/adjustments depending on the evolution stagesof the patient - identified through comprehensiveassessment/ re-assessments ...

... We make this remark for the various components

of a rehabilitation process/ program (in which,

especially in early stages - supra acute/ acute and

also post acute, it prevails RN) because of being

subject to our attempt of systematization/

typological division (mainly for exposure/ teaching

purposes), but in reality the components of clinical

care can not and should not be too separate

a continuous prcess:Preventive, therapeutic and/or rehabilitative steps,whatever they are, represent, in fact, a longitudinal,intrinsic and essential component of overall mana-gement of the patient, covering and helping itsevolution, from the supra acut stage to the finalgoal of any recovery = fully healed (asymptomatic/ without rehabilitation objectives) and - newer - even beyond :

over-performing, including of physical skills

(concept of Human Performance Augmentation):

We shall present further - including with the emphasis of

connections between them and the area where sequen-

ces or programs of properly rehabilitation start -

the major integrated approaches (intricated

with prophylactic and/or therapeutic components) of

Rehabilitation Nursing (RN): ...

To differentiate, within their indisoluble syncretism, theexclusively nursing components are displayed in italics:

continuous inspection of the patients skin (possibleerythematous lesions on decubitus areas), but also ofhis/her linen - humidity - thus to be able to promptly take measures in case of tendency to pressure sores

turns into bed (from 2 to 2 hours, if the patient doesnot have an anti-sores airflow mattress, respectivelyat 4-6 hours, if the patient has such a device) with twodifferent roles, but equally important:

one exclusively of nursing type - prevention of trophic lesions, of pressure sores kind - and another: ...

... kinetologic element, of rehabilitative type

facilitator/ inhibitor antispasticity, consisting of

alternate posturing/ rotating - roll - in inhibitory

reflex positions - possibly in association with other (Berta - 1948 - and Karel - 1950*) Bobath

methods elements

*Eisenberg MG - Dictionary of Rehabilitation. New York: Springer Publishing Company, 1995; http://cirrie.buffalo.edu/encyclopedia/en/article/172/

...anti latch posturing - element of nursing with role of pre-

venting veno-lymphatic stasis and venous thromb-embolism

- but rehabilitative, too :

anticipative posturing, - in positions to compensate the

expected unbalance between: agonists, anta-gonists,

synergists and stabilizing muscles, that will occur, conse-

quent to plegia and further, to the appearance of spasticity,

thus with dual prophylactic role on straining of joints (for

instance: wrists, ankles);

then, when spasticity installs: corrective positions,

through the use of orthoses - antispastic slow stretching -

rehabilitative aim, but also part of self-care (to be chosen

anatomical postures) ...

...bronchial drainage maneuvers - included in the

assembly of postural measures (turns into bed), too - of

nursing and physical-kinetical kinds, as well - together:

inhaling - including oxygen and/or aerosols - therapy, with

humidification/fluidification and expectoration facilitating and/or

instrumental bronchial: aspiration of secretions in the

fauces (or upper trachea - if existing cannula) andventilation training to maintain/ restore breathing

capacity (in this respect, very important - especially in the

subacute stage: cough assistance) ...

Oxygen Concentrators separate oxygen of the air oxygen concentration achieved: 93 3% adjustable capacity up to 5L/min debitmeter graded from 0.5 to 0.5 LPM for adjustment of the oxygen capacity delivered to the patient zeolyth and respectively, bacteriological filters within the input and output circuits furnished to the patient oxygen humidificator23 kg weight, mobile on wheels available for use at home

Nebulizers of individual use: after a quite simple preparatory training, patients or their non-licensed caregivers could use them, on medium/ long - term, including at home. Available substances for such way of administration: water (distilled or sea - in seashore balneary units or alcaline mineral waters, in resorts with cu such natural therapeutic factors) or physiologic saline solution, possibly associated with mucolitics, bronchodilatators - including glucocorticoids -, antibiotics (the latters with some alergiy or intolerance risks). Currently are recomended aerosolizations with physiologic saline solution and/or N-acetylcysteine (N-ACC vials: 3ml - 100mg/ml, i.e. 300mg of N-ACC: 1/3-1 vial and distilled water or physiologic saline solution, up to 7-10 ml): 10-20 min/ session, about 2 sessions/ day, 5-10 days/ session. Within inhalotherapy, there is the Respiration n intermittent Positive Pressure (most often, the inspiration: RIPP/ I+); this - as procedure of assisted mechanical ventilation - especially in association with aerosolotherapy, would possibly result in a supplemen-tary enhancement of the broncho-pulmonary air distribution and of the gazeous exchanges, being mainly recommanded in cases with atelectatic lesions - not too often necessary in a NeuroRehabilitation ward, treating post SCI patients in subacure stage, like our P(n-m)RM Clinic Division; however, if economically possible (including) the association: RIPP + Pneumo-Belt, connectedto the endopneumotherapie apparatus through a related valve,

placed in the upper venter and lower ribbs area*.

*Sbenghe T - Recuperarea medical a bolnavilor respiratori. Ed. Medical, Bucureti, 1983

(Small and handy) secretion aspirator - adjustable degree of the vacuum- vacuum indicator- autoclavablepot: 1l with safety circuit- silicone tubes; antibacterial filter; Nelaton probe- maximal aspiration pressure: - 0, 75 bar- maximal aspiration capacity:14 l/ min- size: 235xx165 x190(h)mm; weight: 2,2 Kg; transportable- intermittent functionning: 20 min.ON/40 min.OFF- use location: home, ward (P(n-m)RM/TEHBA- Clinic Division)

Surgical secretion aspirator (P(n-m)RM/TEHBA- Clinic Division)- adjustable degree of the vacuum- vacuum indicator - 2 autoclavablepots: 2x2 l, with safety circuits- silicone tubes; antibacterial filter- maximal aspiration pressure: - 90 kPa (- 0,9bar); in current functionning: - 40kPa (- 0.4 bar)- maximal aspiration capacity:60 l/ min- mobile on antistatique wheels- size: 460x850(h)x420 mm; weight: 13 kg- functionning: continuous- use location: ward

enteral feeding - rationale/ prerequisites. Mastication (chewing) - the first physiological step in pregastric digestion - accomplishes several tasks, such as: - fragmenting the pieces of solid food primarly introduced in the mouth, into smaller ones, softer and lubricated through mixing with saliva, thus enabling, bysize and softening, to be swallowed - preparation of effective action for digestive enzymes - which act only on the surfaces of food particles - by significantly consequent increase of chewed food pieces surface area, including with subsequent facilitation to empting - also, without being mechanically aggressive on the gastro-intestinal mucosa - from the stomach, within the physiologic phases of digestion, of the grinded/ with fine particulate consistency, of the ingested aliment. Especially regarding rawvegetables and many kinds of fruits, their masticatory breaking is mandatory inorder to expose for digestion their covered by celulose fibers nourishing content. Mastication is a complex motor act, consistently based on a reflex component (chewing reflex). This is initiated by sensory (see below) and/or - under certain conditions, such as excitation of the cerebral cortex near the ... areas for taste and/or smell - some sensorial inputs, and mainly closed in/ controlled by nuclei in the brain stem (mainly specific reticular areas in the brain stem taste centers - in principal for the rhythmical chewing movements) but most probably, with superior centers - hypothalamus, amygdala - involvement and respectively, with the involved muscles peripheral innervation through the motor branch of the trigeminal nerve ...

(*after Imagini pentru mastication - http://www.google.ro/#hl=ro&sclient=psy-ab&q=mastication&oq=mastication&gs_l=hp.1.0.0l3j0i30.22460.41474.0.45610.11.9.0.1.1.0.4797.18308.0j3j1j7-1j0j4.9.0...0.0...1c.1.prAUtjrsqmk&pbx=1&bav=on.2,or.r_gc.r_pw.r_qf.&fp=96f8a44148271824&biw=998&bih=665) ...Hence, basically, introduction into the mouth of food (or chewing gum) generates a reflex relaxation of the lower jaw muscles with the consequent dropof it , generating, in turn, a stretch reflex which determine their contraction, that automatically raises the jaw to cause closure of the teeth; to this grinding action also contributes the tongue and, to a lesser extent, the lips and cheeks; ...

...

in the mean time, sticking the pieces of food to the linings of

the mouth, (re)initiates the reflex relaxing of the lower jaw

muscles, and so on.*

Disturbances, of different causes (specifically neurological ones -

and/or sometimes skeletal ones, in polytaumatic circumstances, for instance: in maxilary and/or jaw fractures), may impose

temporary (gastro-)enteral feeding ... *Guyton A.C., Hall J.E. - Textbook of medical physiology (11th edition). Elsevier Saunders, 2006; http://biology.about.com/library/organs/blpathodigest4.htm

Enteral nutrition or Tube feeding. is when a special liquid food mixture containing protein, carbohydrates (sugar), fats, vitamins and minerals, is given through a tube into the stomach or small bowel. ... Tube feeding can be given through different types of tubes. One type of tube can be placed through the nose into the stomach or bowel. This tube is called a nasogastric or nasoenteral feeding tube. Sometimes the tube is placed directly through the skin into the stomach or bowel. This is called a gastrostomy or jejunostomy.*

*http://www.nutritioncare.org/wcontent.aspx?id=266)

As a consequence of different causes/ etiologies affecting the nervous system and/or the skeleton, in polytraumatic context (for example: fractures of the jaw and/or mandible, which directly or indirectly - due to the need for therapeutic restraint - prevents oral motility) may affect chewing and/or swallowing.

In cases of TBI: cranial nerve damage can affect both mastication - mainly related to the trigeminal (V) motor branch*- and swallowing (also a reflex act - except for its first time: oral, which is voluntary and to which the contributive innervation consistspredominantly in pairs: IX, X and XII)**,*** *Guyton AC, Hall JE - Textbook of Medical Physiology (11th edition). Elsevier Saunders, 2006**Palmer JB et al. - Rehabilitation of Patients with swallowing Disorders - In: Braddom RL (ed.), et al. Physical Medicine & Rehabilitation (3rd edition). WB Saunders Company, Philadelphia, USA, 2007***SF Noll et al. - Rehabilitation of Patients with swallowing Disorders - In: Braddom RL (ed.) et al. Physical Medicine & Rehabilitation (2nd edition). WB Saunders Company, Philadelphia, USA, 2000

... Deglutition (swallowing) - is the second/ last physiolo-gical step in pre-gastric digestion.It is a quasi autonomous - largely without conscious, will or awareness - and continuous, very complex, coordinated, process, occurring with a normal - while idle and inhibited, in significant amount,during concentration and emoional excite-ment - rhythm of (such) an act/ minute, no matter if the individual is awake or asleep; the rationale of its permanent/ periodicity is the drainagefrom the mouth into the esophagus of the saliva, thus preven-ting the entrance of this fluid in the larynx - as aspiration of any other substance but air in the respiratory tract may causemost severe health troubles, such as aspiration broncho- pneumonia, which may be, including life threatning*,** ... *Ropper AH, Samuels MA - Adams and Victors Principlesof Neurology.Ninth edition, McGraw-Hill Companies Inc., USA, 2009 **http://biology.about.com/library/organs/blpathodigest4.htm

... The main vital consequence of swallowing ismaking possible feeding (aspiration may occur now, too). Deglutition comprises three phases/ steps: oral, pharyngeal, esophageal. Only the first one is voluntary, the other two being reflex. Initially, the alimentary bolus - prepared and placed on thetongue in the preparatory stage of this phase - is pushed by the tongue into the pharynx - in the second, propulsivestage* of the oral phase and further, into the esophagus (after upper esophageal sphincter opens), normally in very safe conditions: closing alternative routes of escape**,*** as previously pointed out ... *Palmer JB et al. - Rehabilitation of Patients with Swallowing Disorders - in: Braddom RL (ed.), et al. Physical Medicine & Rehabilitation (3rd edition). WB Saunders Company, Philadelphia, USA, 2007 **Noll SF et al.- Rehabilitation of Patients with Swallowing Disorders - in: Braddom RL (ed.) et al. Physical Medicine & Rehabilitation (2nd edition). WB Saunders Company, Philadelphia, USA, 2000 ***http://biology.about.com/library/organs/blpathodigest4.htm

...The airway is closed by sequential contractions of thearytenoid-epiglottic folds and below them, the false cordsand then the true vocal cords, which seal the trachea. AII of these muscular contractions are effected largely by cranial nerve X (vagus). The palatopharyngeal muscles pull the pharynx up over the bolus and the stylo-pharyngeal muscles draw the sides of the pharynx outward (nerve IX). At the same time, the upward movement of the larynx opens the crico-pharyngeal sphincter. A wave of peri-stalsis then begins in the pharynx, pushing the bolus through the sphincter into the esophagus. These muscles relax as soon as the bolus reaches the esophagus* *Ropper AH, Samuels MA - Adams and Victors Principles of Neurology.Ninth edition, McGraw-Hill Companies Inc., USA, 2009

...Reflex swallowing requires is medullary located (but with organization of related muscles coordinated/ integratedsequence activity in the brain stem roughly comprising a swallowing center in a region close to the respiratory centers) and may function including in vegetative and locked-in states.

Additionally cortical regions involved in swallowing: the inferior precentral gyrus and the posterior inferior frontal gyrus - lesions in these parts of the brain result in most severe cases of dysphagia.*

*Ropper AH, Samuels MA - Adams and Victors Principles of Neurology.Ninth edition, McGraw-Hill Companies Inc., USA, 2009

.

.*.(After Palmer et al. - in: Braddom et al., 2007)

The existence of with post TBI disorders: aspiration pneumonia dysphagia - possibly concomitant, in some patients cerebrovascular lesions, with tracheal cannula and thus the presence of (additional) risk for food aspiration, leading to a redoubtable complication, possibly fatal, especially in frail patients, such as those - may require temporary or indefinite (gastro)enteral feeding.

This is all the more marked as such patients have a po-tential prognostic severity, including the tendency to(dis) nutritional and metabolic distubancies (post-aggres-sive/ lesion hipercatabolism) and consecutive systemic predisposing to "complex cachexia* *Alexianu D Come i tulburri de contien n terapia intensiv. Viaa Medical, nr. 29-30, 23 iulie, 2010

Thus, it is considered that a weight loss of more than 10% - maximum 15% (the decrease to a body weight less than 90% of the ideal) is significant malnutrition !. It is also known as being useful for monitoring - including from this point of view - the value of serum albumin (hypoalbuminemia - correlated with lymphopenia*).

It is estimated that in determining food intake needs, patients (considered in acute/ post-operative "critic" and for the category to which we refer) the requirered enteral feeding, needs should be calculated as basal/ rest plus the surplus consumption due to the consumptive morbid element; their initial metabolic state should also be considered

*Noll SF et al. - Rehabilitation of Patients with Swallowing Disorders - in: Braddom RL (ed.) et al. Physical Medicine & Rehabilitation (2nd edition). WB Saunders Company, Philadelphia, USA, 2000

Body mass index (BMI), the quotient of weight in kilo-grams divided by height in meters squared, is typically between 22 and 27.7.

Having a long half-life (20 days), the albumin valuedoes not reflect acute nutriional deficiencies, but a level less than 3.5 g/dL raises nutriional concerns.

The total lymphocyte count (the product of the total leukocyte count and the percentage lymphocytes) corre-lates with the albumin value and is decreased in mal-nutrition: count less than 1400 may indicate nutrition problems.* ...

*Noll SF et al.- Rehabilitation of Patients with Swallowing Disorders - in: Braddom RL (ed.) et al. Physical Medicine & Rehabilitation (2nd edition). WB Saunders Company, Philadelphia, USA, 2000

...In cases of malnutrition, the daily caloric needs are traditionally de-termined with the Harris Benedict formula for basal energy expen-diture (BEE), which takes into account weight, height, and age:BEE for women = 655 + (9.6 X weight [kg]) + (1.8 X height [cm]) - (4.7 X age [yr])BEE for men = 66 + (13.7 X weight [kg]) + (5 X height [cm]) - (6.8 X age [yr]). This formula was derived from healthy individuals at rest. Adjustment factors have been defined for activity and injury. General hospital patients require 120% of BEE, whereas medically stressed patients can require 150% to 200%. An estimate of caloric need is typically 25 to 30 calories/kg of ideal body weight. Protein requirements are typically estimated at 1.0 to 1.5 g/kg/day, but are increased in catabolic states and decreased in significant renal or liver disease* ...

*Noll SF et al.- Rehabilitation of Patients with Swallowing Disorders - in: Braddom RL (ed.) et al. Physical Medicine & Rehabilitation (2nd edition). WB Saunders Company, Philadelphia, USA, 2000

For example, the Benedict formula allows calculation - differentia-ted with adjustment coefficients between women and men - of the"basal energy expenditure (BEE)"- including in situations of malnu-trition - but from normal individuals patterns - based on weight, heightand age) and according to this benchmark, the daily rest caloric needs. Thus, taking into account the above mentioned pathological particu-larities in literature, total nutritional needs (including protein-derived calories - 0.8 - 1.5 g/ dl) are estimated in such patients to 120% (pos-sibly widened in cases of morbid stress to even 150% - but bearin mind that overfeeding poses equally important risks) and in the absence of indirect calorimetry, 25-30 (even 35 kcal/ kg/ day* nee-ded to be, also attained in the first 2-3 days after the initiation of enteral feeding*, **, *** *Noll SF et al. - Rehabilitation of Patients with Swallowing Disorders - in: Braddom RL (ed.) et al. Physical Medicine & Rehabilitation (2nd edition). WB Saunders Company, Philadelphia, USA, 2000 **Roman CV, Brnzeu C, Brnzeu A - Protocol for enteral nutrition to critically ill patient (pdf) - http://ati.medical congresses.ro / Show / Files / Guides% 20and% 20protocoale/2006 ***Grecu I, Ologoiu D Grinescu I (pdf) - Clinical Nutrition critically ill patient (Romanian Society of ATI Recommendations - SRATI - 2009 and the Romanian Society of Parenteral Nutrition - ROSPEN - 2009

As such, it would be optimal, under the methodological aspect - in the circumstances of coverage with optimal, (supra)specialized staff (which is not always possible, especially in times/ circumstances marked by economic constraints - which inevitably affect the resources for medical care, including neurorehabilitation) - that in every medical establishment where patients with such problems are admitted the enteral feeding be prescribed by medical professionals specialized in this respect.

... A such desirable organizational situation is not objectively (yet) possible ubiquitously. In post TBI patients in subacute and sub-chronic/ post-acute phases there is usually the possibility to choose the method of batch/ bolus enteral feeding, this form of nutrition being more accessible (including/ very important - see below feasible by care givers, as it requires no special equipment, being administred by syringe and is cheaper).

This method does not interfere with insulin therapy in diabetics, inducing a pattern of gastric digestion closest to the physiological one (including an intense acid secretion - protection from microbial colonization), but is, on the other hand, less precise with regard to the control on caloric intake and also, exposing more to dyspeptic phenomena - vomiting, diarrhea/ constipation - associated malnutrition risks.* ... *Roman CV, Brnzeu C, Brnzeu A - Protocol for enteral nutrition to critically ill patient (pdf) - http://ati.medical congresses.ro / Show / Files / Guides% 20and% 20protocoale/2006

Whether a tube placed in the jejunum affords greater protection from aspiration than a gastric tube is unclear. Data from patients hospitalized for acute conditions who were enterally fed by various routes suggest that the incidence of aspiration is only 2.4 per 1000 tube-feeding days, and there is no excess mortality and only minimal morbidity. Continuous feedings by infusion pump result in the least gastric distention and might be preferable in patients at high risk for reflux aspiration. Continuous feedings are also useful in patients with poor enteral motility or in persons who require hypertonic formulas. Intermittent or bolus feeding, however, is less disruptive to rehabilitation activities and to general daily living.*

*Noll SF et al.- Rehabilitation of Patients with Swallowing Disorders - in: Braddom RL (ed.) et al. Physical Medicine & Rehabilitation (2nd edition). WB Saunders Company, Philadelphia, USA, 2000

Overall, however, practical experience gained including the P(n-m)RMClinic Division of TEHBA, in the administration of this form of nutrition indicates - taking into account the context of current realities - the acceptable possibility that this type of IC/ RN is given by the patient's family (see futrher), after the initiation and dynamic adjustment by the neurorehabilitation team members

Given these considerations, patients requiring enteral feeding can receive a diet adequate for daily nutritional needs through bolus administration (slowly: maximum 20ml/ min*), of liquid and semisolid/ semiliquid/ minced food*, **, plus the (remaining) needed hydration - in the following ways/ devices: nasopharyngeal tube (or rarely, through an oro-pha-ryngeal tube: quite unbearable, useful when the nasal approach is not possible, for example in patients with controlled breathing ventilator in ICU) gastric or jejunal tube - if it should be necessary that such nutrition be prolonged more than 3-4 weeks*** through gastro-stoma (or, less commonly, by jejuno-stoma) ... *Roman CV, Brnzeu C, Brnzeu A - Protocol for enteral nutrition to critically ill patient (pdf) - http://ati.medical congresses.ro / Show / Files / Guides% 20and% 20protocoale/2006 **Grecu I, Ologoiu D Grinescu I (pdf) - Clinical Nutrition critically ill patient (Romanian Society of ATI Recommendations - SRATI - 2009 and the Romanian Society of Parenteral Nutrition - ROSPEN - 2009 ***Boake C, Francisco GE, Ivanhoe CB, Kothari S - Brain Injury Rehabilitation - in: Braddom R.L. et al. - Physical Medicine & Rehabililitation (2nd edition). W. B. Saunders Company, Philadelphia, U.S.A., 2000

When nutritional needs can be met orally only partially ornot at all, enteral feeding is the usual route of choice unless there is a need to eliminate the risk of aspiration completely. An initial feeding route is easily accomplished with a soft naso-gastric feeding tube. If enteral feeding is prolonged, the use of a gastrostomy tube, typically placed percutaneously, is better toleratedby the patient, provides the prescribed nutrition more re-liably, and results in more weight gain than the long-term use of a nasogastric feeding tube. The absence of a na-so-gastric tube also facilitates swallowing interventions, although a nasogastric tube is not a contraindication to therapeutic feeding.* *Noll SF et al.- Rehabilitation of Patients with Swallowing Disorders - in: Braddom RL (ed.) et al. Physical Medicine & Rehabilitation (2nd edition). WB Saunders Company, Philadelphia, USA, 2000

Physical/ bedside swallow evaluation - is mandatory and includes:observation of swallows for solid and liquid food, dry swallow, possible behavioral/ dietary modifications. Clinical test for liquid swallows is recommended to use asmall sip of water, with further progressive cantitative trials. The frequently cited 'water test' involves continu-ously drinking a determined amount of water and moni-toring for aspiration or penetration symptoms, inclu-ding: coughing, dyspnea, and throat clearing. Useful in screening but, it does not detect silent aspira-tion and respectively, the mechanism of a swallowing dis-order and swallowing with more advanced consistencies.* *Palmer JB et al. - Rehabilitation of Patients with Swallowing Disorders - in: Braddom RL (ed.), et al. Physical Medicine & Rehabilitation (3rd edition). WB Saunders Company, Philadelphia, USA, 2007

During the oral-phase evaluation, note labial seal, rotarymastication and presence of oral residue, as well as duration of oral phase.

Pharyngeal signs of dysphagia include delayed swallow onset, coughing or throat clearing after swallows, wet vocal quality or dyspnea following trials.

Silent aspiration is a severe matter including because there are no accurate clinical signs/ and hence efficient related assessments. The clinician must detect risk factorsfor aspiration (compromised respiratory system, ineffectiveprotective mechanism - as demonstrated by impaired vocalcord movement and weak cough; reduced cognitive status - especially related to sedating medications, which can diminish motor control).*

*Palmer JB et al. - Rehabilitation of Patients with Swallowing Disorders - in: Braddom RL (ed.), et al. Physical Medicine & Rehabilitation (3rd edition). WB Saunders Company, Philadelphia, USA, 2007

A modern, efficient technique of installation of gastric stoma is by simultaneous percutaneous and endoscopic maneuvres (Percutaneous Endoscopic Gastrostomy - PEG) *, **

Given the previously exposed, a very broad estimate: the nutrition required for a person on enteral feeding, with a weight of approx. 70 kg, the daily caloric needs would be around 1750-2100 kcal; also being provided hydration around (possibly slightly more) 2l/ day *http://www.nutritioncare.org/wcontent.aspx?id=266 **Boake C, Francisco GE, Ivanhoe CB, Kothari S - Brain Injury Rehabilitation - in: Braddom R.L. et al. - Physical Medicine & Rehabililitation (2nd edition). W. B. Saunders Company, Philadelphia, U.S.A., 2000

To the point, but purely orientative, as an example, related to enteric food boluses, we provide here some methodological notes, including the hourly allocation to cover management circadian administration, along with suggestions on some kitchen products that can be used. Thus: 3 meals (approximately 8 am, 14 and 20) and 2-3 snacks (at around 10, 16, possibly to 6 - see below), each consisting of 200-300 ml (possibly 400 ml *, depending on the level of malnutrition and digestive tolerance) liquid and semisolid food/ semiliquid/ minced (bones soup/ minced vegetables with meat, mashed liver/ fish, mashed potatoes or minced rice/ rice with meat, eggs with mashed potatoes, yogurt/ yogurt + chop-dip crackers, rice milk, biscuits with milk, cottage cheese, mashed bananas) and 3-4 hydration boluses of 150-200 ml each: plain water/ milk/ tea/ fruit juice/ sauce (at 12, 18 and 24; at 6 o'clock - as mentioned above, depending on the evolution/ nutritional needs and digestive tolerance - may be associated hydration and a snack). In addition - is also fluid intake, which summarizes the whole hydration - after each use/ feeding, nasogastric or gastrostoma tube should be "washed" with 30-40 ml of water* *Roman CV, Brnzeu C, Brnzeu A - Protocol for enteral nutrition to critically ill patient (pdf) - http://ati.medical congresses.ro / Show / Files / Guides% 20and% 20protocoale/2006

It is noteworthy that food being liquid and semisolid/ semiliquid/ minced/ mashed brings self-important quantum fluid, therefore liquid intake reaches - or easily exceeds - 2000ml/ day.

This amount should not be exceeded if the patient medication also requires infusions (adding to the fluid and electrolyte contribution).

It is not necessary to insist that feeding modality different from the physiological one has many drawbacks and risks, therefore the sooner the patient regains mastication and swallowing, the faster the overall (neuro -) recovery

Training the patient - if his/her condition allows cognitive cooperation - and/ or caregivers can be made accessible (by providing notions, explanations, and concrete demonstrations - all made as clear, simple and understandable), as it involves no medical training from their part to understand/ learn those instructions.

Thus, subsequently to the training process, the patient and/or his relatives will be able - and recommended - to get involved (and) to resume per os feeding (in the spirit of the modern general concept, according to which patients and their families are considered a team/ recovery partners, working together for the optimization of assistance and obtained results.*

*Haas, cited by Delisa JA , Gans BM (Eds.) et al. - Rehabilitation Medicine (3rd edition). Lippincott Williams & Wilkins, Philadelphia, USA, 1998

IC/ RN, including the steps to resume feeding in a natural way, have a high rehabilitative value: It is based (because mastication and swallowing, as mentioned before, are reflex acts - but with a voluntary component) on both the reflex component facilitatory for re-estabilishing/-conditioning, as well as on the conscious one, capable of re-learning

Thus, by using strategies/ compensation techniques (posture of the head with slight chin anteflection, possibly associated with tilt toward the side with better motor control and/or the rotation right/ left of the head - all leading to the most intense contact between the inges-ted food bolus and the inside of the mouth, to stimulate motor multi-signal mechanisms for preparing chewing and swallowing - for-ced swallowing - including of "supraglotic type" - and/or repeated/ double, possibly interspersed with oral introduction of small quantities - initially very small - of liquid and so on*, **), which are accessible and relatively simple - patient involvement in re-acquiring normal patterns of these functions will be more possible, the chances of their recovery will increase

*Cifu DX, Kreutzer JS, Slater DN, Taylor L - Rehabilitation after Traumatic Brain Injury - in: Braddom R.L. et al. - Physical Medicine & Rehabililitation (3rd edition). W. B. Saunders Company, Philadelphia, U.S.A., 2007 *Noll SF et al. - Rehabilitation of Patients with Swallowing Disorders - in: Braddom RL (ed.) et al. Physical Medicine & Rehabilitation (2nd edition). WB Saunders Company, Philadelphia, USA, 2000

Resumption of oral feeding requires the supplier of IC/ RN - in ad-dition to the necessary (but relatively simple) applied skills - the es-sential kindness, care and patience: with the resumption of per os natural feeding/ hydration, the patient should receive semisolid and/ or semiliquid food in quantities - as shown, initially very small, in gradually increasing or decreasing amounts of consistency, depending on the prevalence, from this point of view, of dysphagia: liquid or solid - so that the duration of such steps is relatively large; nutritional needs must, of course, be met as already exposed, and this leads to a complex of related activities related to resuming the feeding by mouth, sometimes very time consuming and demanding (primarily for the feeding person, but also for the fed one - which in fact should also be taken into account in order to avoid overloading - these patients being still usually fragile)

In addition patient reactions should be carefully monitored for signs of gag, so that the care giver may be able, on the one hand, to immediately stop feeding and on the other, to position the patient with the pharynx in a proclive posture and possibly taping him/her, to facilitate expectoration, and avoid unwanted aspiration phenomena.

Obviously, in case of such an incident, medical personnel should be immediately alerted, the most effective measure in this situation - in addition to posture and taping on set - being the immediate placement of the patient in the ICU - where there are adequate appliances both for suction and - major assistance/ support, and gene-ral respiratory and also by the situation and evolution, with rapid access to specific means of exploring swallowing: ultrasound, fluoroscopy/ contrast barium Xray, video-fluoroscopy or newer and easier to be tolerated - including the lack of radiation and the possibility of using food or semi-liquid/solid instead of contrast substance - optical fiber endoscopy, possibly computer scintigraphy with technetium 99m coloidal sulphur*, **, ***).

...*Anghelescu A, Onose G, (n colab. cu) Mihescu AS Ghid de diagnostic/ evaluare, principii terapeutice i neuroreabilitare n suferine dup traumatisme cranio-cerebrale. Ed. Universitar Carol Davila Bucureti, 2011**Cifu DX, Kreutzer JS, Slater DN, Taylor L - Rehabilitation after Traumatic Brain Injury - in: Braddom R.L. et al. - Physical Medicine & Rehabililitation (3rd edition). W. B. Saunders Company, Philadelphia, U.S.A., 2007***Noll SF et al. - Rehabilitation of Patients with Swallowing Disorders - in: Braddom RL (ed.) et al. Physical Medicine & Rehabilitation (2nd edition). WB Saunders Company, Philadelphia, USA, 2000

Given these considerations, patients requiring enteral feeding can receive a diet adequate for daily nutritional needs through bolus administration (slowly: maximum 20ml/ min*), of liquid and semisolid/ semiliquid/ minced food*, **, plus the (remaining) needed hydration - in the following ways/ devices: nasopharyngeal tube (or rarely, through an oropharyngeal tube:quite unbearable, useful when the nasal approach is not possible, for example in patients with controlled breathing ventilator in ICU) gastric/ (or) jejunal tube if it should be necessary that such nutrition be prolonged morethan 3-4 weeks*** - through gastro-stoma (or, less commonly, by jejuno-stoma). ...

*Roman CV, Brnzeu C, Brnzeu A - Protocol for enteral nutrition to critically ill patient (pdf) - http://ati.medical congresses.ro / Show / Files / Guides% 20and% 20protocoale/2006**Grecu I, Ologoiu D Grinescu I (pdf) - Clinical Nutrition critically ill patient (Romanian Society of ATI Recommendations - SRATI - 2009 and the Romanian Society of Parenteral Nutrition - ROSPEN - 2009***Boake C, Francisco GE, Ivanhoe CB, Kothari S - Brain Injury Rehabilitation - in: Braddom R.L. et al. - Physical Medicine & Rehabililitation (2nd edition). W. B. Saunders Company, Philadelphia, U.S.A., 2000

... appropriate methodological massage -abdominal and of the limbs (for prevention ofintestinal stasis - stimulating bowel -, respectivelyof venous-limphatic stasis) and shaking/ tapotageto facilitate expectoration

passive limb mobilization - circulationpumping with dual purpose: of improving tissuesnutrition/ maintaining trophicity and respective-ly, of the passive range of motion (PROM) andalso for prevention of venous thromb-embolism ...

... assisting/ trainig the process (usually required)

to evacuate urine (bladder catheterization, initially

continuously, and subsequently, intermittently - for

which previous training may be done by clipping

the probe - then, intermittent catheterization itself is

an element of training - with some limited recovery

facets on bladder control)

bowel management and control training - the

above considerations can be similarly made concer-

ning digital annal evacuation/ manipulation) ...

Some of the previous mentioned measures include,

critical steps; therefore they are mandatory and

urgent (e.g.: tracheal/ brochial aspiration, urine/ stools

evacuation) and do not require patients

effort - such as for active kinetotherapy.

This is mainly the case for RN, set immediately

after taking in charge the inpatient - still in acute

spinal shock and/or even further, if having

hyperchronic evolution - usually characterized by

weakness and fragility

To these, in the post acute phase (usually withduration of weeks), begin to be added, progressivelly, physical - kinetological more pro-active procedures, towards theswitch, from

upmost RN to mainly properly rehabilitative

programmes:

assist, facilitate or (re)training of active movements - where appropriate, also skills in the limbs - and/or trick gestures, with propensity for self care

***********************