Approaches to patient management

Published on 03/03/2015 by admin

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Last modified 03/03/2015

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19 Approaches to patient management

Introduction

Perhaps the greatest challenge in clinical functional neurology is integrating the theoretical knowledge that one has acquired and results obtained via practical testing into a coherent approach that can be applied to a patient’s presentation. This is so challenging because everything that happens to us in our daily lives can in some instances be important clinically and in others not matter in the slightest. Everyday events involving sensory stimulation, deprivation, and learning can effectively weaken synaptic connections in some circumstances and strengthen them in others. Just because structural or functional changes may not initially be detected following clinical examination does not rule out the possibility that important biological changes are nevertheless occurring. They may simply be below the level of detection with the techniques available to us.

In this chapter I will try to highlight the approach that I and other neurologists have taken with a variety of patients that have presented to me or other functional neurologists that have graciously supplied the case details to me for this chapter. In all cases, I have tried to present a discussion of why the therapy was applied and the outcome of the treatment, when available. Some of the physical examination findings in some cases are not reported as completely as I would have liked, but in real practice one does not always have a complete picture but is expected to move ahead regardless. In this respect, I have tried to present the cases as they were presented to me or as they have been recorded in my notes. This should give the reader a better feel for clinical application.

Case 19.1

Discussion

The pattern of signs and symptoms revealed during TWB’s functional neurological consultation provide an insight into the possible levels of dysfunction in the longitudinal and horizontal planes of the neuraxis. Localisation of the lesion is assisted by a comprehensive knowledge of the afferent and efferent connections throughout the neuraxis and an ability to ascertain the frequency of firing (FOF) and integrity of fuel delivery in different regions and systems. History and examination directed at localising the symptoms to a specific level of the neuraxis, including the following well-defined functional levels, is necessary:

Asymmetry or dysfunction in each of these components of the nervous system can directly or indirectly affect various motor, sensory, visceral, and mental functions or indicate a dysfunction in any of these modalities.

Most importantly from a functional neurological perspective, asymmetry or dysfunction in the most influential components of the nervous system should be considered:

In the case of TWB, he showed signs and symptoms of left cerebellar and right cortical dysfunction. This was expressed in the physical exam by his relative lack of coordination on the left, his pupillary TND on the right, Romberg’s test falling to the left, his lack of ability to concentrate, and the hyperresponsiveness of his right-sided reflexes, which indicates increased tone due to decreased activation of the PMRF ipsilaterally.

ADHD is thought to occur as a result of an inability of the individual to maintain attention on a primary task because of an inability to inhibit or suppress motor responses to incoming sensory stimuli (Barkley 1997). Some consistency has been found in people with dysfunctions of the right frontal cortex in that they express great difficulty in suppressing motor responses to incoming sensory stimuli (Sergeant 2000). The right frontal cortex functions in some manner to inhibit inappropriate motor responses in a normally functioning brain. The activity of the right frontal cortex relies heavily on the dentato-ponto-cortical and dentato-rubral-thalamo-cortical pathways. Asymmetric reduction in afferent information to the cerebellum because of asymmetric dysfunctional peripheral afferent pathways may cause diaschisis in functional circuits downstream from the cerebellum, in this case the contralateral cortex. In this case, the application of manipulation to increase the afferent stimulus received by the cerebellum and other therapies aimed at increasing the activation of the right frontal cortex were successful in reducing the patient’s symptoms and ultimately his state of disability.

Case 19.2