NeuroRehabilitation

Lightning is responsible for a wide spectrum of neurologic complications. Many of the persistent symptoms require long-term neurorehabilitation. The lightning-related neurologic conditions are divided into four categories. Category I consists of signs and symptoms that are temporary and usually benign. Category II conditions are prolonged or permanent produced by significant central nervous system lesions. Two of the most devastating complications are lightning-related encephalopathy and myelopathy. The disabilities that accompany these lesions call for concentrated neurorehabilitation. A large number of patients are afflicted with neurobehavioral symptoms that may last for months or years. Category III contains delayed neurologic syndromes. Category IV encompasses neurologic lesions that are not directly activated by the lightning strike but are the result of trauma secondary to falls or blasts effects.

The sensible course for individuals at risk is to learn and follow lightning safety recommendations.

While spinal cord injuries caused by lightning strike or electrical shock are rare, their clinical manifestations pose unique challenges to the clinician who must anticipate the interaction of multiple system involvement with the altered physiology of spinal cord injury. Spinal cord damage may be secondary to the direct effects of electrical current passing through neural tissue producing immediate or delayed impairment. Alternatively, lightning strike and electrical shock may lead to spinal cord damage due to the secondary consequences of injury such as spinal fractures sustained after a fall. In addition to effects on the spinal cord, electrical trauma may result in injury to the brain, peripheral nervous system, musculoskeletal system, skin, and cardiovascular system. This article will review the neurorehabilitation approach to this rare and challenging group of patients.

The most devastating casualties in lightning and electrical trauma patients are the result of lesions of the nervous system, and especially lesions of the brain. The brain injuries can be divided into three categories: global dysfunction; focal brain injuries; and behavioral-cognitive sequelae without gross physical signs. Lightning injuries are usually the result of outdoor sports and leisure activities. Most electrical trauma cases are the result of workplace accidents. Rehabilitation planning should begin early after the incident and often needs to be continued for a long time. The goal of the rehabilitation team is to maximize functional return in patients with deficits related to brain lesions. The neurorehabilitation team includes the neurorehabilitation physician, physical therapists, occupational therapists, psychologists, speech therapists, and case managers.

Autonomic nervous system (ANS) dysfunction is a serious complication of lightning and electrical trauma (L/ET). The ANS regulates the normal vegetative functioning of many organ systems. When ANS is compromised after lightning and electric trauma, patients are vulnerable to serious medical problems. Three conditions of ANS dysfunction of particular concern for L/ET patients are complex regional pain syndrome (CRPS), cardiovascular abnormalities, and keraunoparalysis (KP). The patient with CRPS presents with pain, hyperpathia, sweating, and edema hours to days after trauma. Neurorehabilitation is exceedingly important. A primary goal is to keep the affected extremity mobile and functional. Some patients benefit from sympathetic blockade. Cardiovascular abnormalities associated with lightning and electrical trauma can be life threatening. Care for these patients require a multidisciplinary team including a cardiologist. Keraunoparalysis is a frightening and distressing complication of lightning strikes. The syndrome consists of limb paralysis, sensory symptoms, pallor, coolness and absent pulses. Release of excessive catecholamines is said to be responsible for these findings. Fortunately, the condition is transient.

Neurobehavioral problems after lightning and electrical injuries are diverse. Commonly reported are decreased cognitive function, pain syndromes, depression, posttraumatic stress disorder, and significant alterations in social and work roles. While the problems resemble those following other kinds of accidents, the injury scenarios for lightning and electrical trauma are unique, and seem to invite more skepticism and controversy in medical and legal realms when the survivors seek help. Studies of lightning and electrical injuries have identified disabling neuropsychiatric changes for some survivors, often persistent and occasionally progressive, that appear weakly related to litigation status, inconsistently related to injury scenarios, and likely influenced by individual premorbid emotional and coping patterns. Standards of care in the fields of brain injury, behavioral medicine, and psychotherapy can inform rehabilitation strategies. Proper assessment is important, as well as an individualized approach to treatment. Multidisciplinary intervention focuses on managing symptoms, learning compensatory skills, providing psychosocial support, and preventing maladaptive behaviors. It has been therapeutic for some patients to become activists for better awareness and prevention.

Electrical burn injuries are complicated because of damage to many structures including: blood vessels, muscles, nerves, tendons, bone and skin. Surgeons must confront many problems such as wound healing coverage, scarring, loss of nerve and tendons, progressive joint stiffness and amputation. The goals of burn therapists are to achieve wound healing, functional recovery, and good cosmetic results. Rehabilitation is both preventive and therapeutic and is a fundamental part of managing these patients. In this article, rehabilitation is discussed with emphasis on the following: pain management, wound coverage, positioning, splinting, and exercises (range-of-motion and ambulation). The treatment and prevention of hypertrophic scarring is evaluated. Finally, the use of engineering and assistive technologies for rehabilitation of the electrical burn injured patient is discussed. Successful management of electrical burn injured patients involves communication among the different burn specialists, such as surgeons, anesthesiologists, neurologists, nurses, and kinesitherapists; engineers from the garments/prostheses companies; psychologists; and the patient him/herself.

Prior to1989 no known support group existed for victims of lightning or electrical shock injury and their families. A lightning strike survivor of twenty years, Steve Marshburn, recognized the need both from his personal experience and after meeting two other survivors. With his wife and psychologist, he formed Lightning Strike and Electric Shock Survivors International. The organization has grown nearly one hundredfold from the thirteen who attended the first annual meeting. The support group serves people from around the world, has produced a number of publications, participated in research about these injuries and has become active in prevention activities. This paper will describe some of the factors that have led to such success for the organization.

Repetitive magnetic stimulation is able to reduce spastic tone increase after applying it at the spinal cord. It was also found to induce frequency-dependent changes in H-reflex. In a small pilot investigation we stimulated a patient with severe spasticity of the lower limbs and applied different stimulation frequencies. The aim was to look for a clinical measurable effect of spastic reduction depending on the applied frequency. We were unable to show such a dependency, but could confirm the spastic-reducing effects of a peripheral repetitive magnetic stimulation using supratheshold intensities.