ASISH K DASWELLNESS RX PHYSIOTHERAPY CENTRE

NEURO REHABILITATION UNIT

www.akdwellnessrx.comphysioakd@gmail.com

response@akdwellnessrx.com

dasishkumar@yahoo.in

Neuro RehabilitationNeuro Rehabilitation

Definition:

• “A process whereby patients who suffer from impairment following neurologic diseases regain their former abilities or, if full recovery is not possible, achieve their optimum physical, mental, social and vocational capacity.”

Neuro RehabilitationNeuro RehabilitationDefinition:Wikipedia – “a complex medical process which aims to aid recovery from a nervous system injury, and to minimize and/or compensate for any functional alterations resulting from it.”Popovic & Sinkjaer(2003)-comprises methods & technology for maximizing the efficiency of preserved neuromuscular structures in human with motor disability

Common words used in Common words used in RehabilitationRehabilitation

•Impairment-refer to the loss of structures or function•Disability-refer to limitations or restrictions resulting from the impairments•Handicap-refer to the inability to perform social/vocational functions resulting from impairment

Neuroplasticity/Brain Neuroplasticity/Brain PlasticityPlasticity

Definition:

•The capability of the brain (or the CNS) to reorganize by forming new neural connections throughout life.

•It allows the neurons in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in the environment.

Cerebral StrokeCerebral Stroke

Demographics:•Leading cause of disability!•15M stroke cases/year worldwide•5M die•5M permanently disabled•Overall mortality is declining•Long-term survival post-stroke is improving

Five Basic Principles Five Basic Principles Governing NeuroplasticityGoverning Neuroplasticity

PRINCIPLE No. 1:BODY PARTS COMPETE FOR BRAIN REPRESENTATION!• “Use dependent plasticity” > “experience dependent plasticity”•“There is a need for the brain to use experience to initiate a new synaptic connection between neurons”•“the more a part is used the bigger its area of representation in the brain that correlates with improved function”•Opposite effect is “learned non use”

Five Basic Principles Five Basic Principles Governing NeuroplasticityGoverning NeuroplasticityPRINCIPLE No. 2:THE IPSILATERAL & CONTRALATERAL HEMISPHERE CAN CONTRIBUTE TO MOTOR CONTROL!•If 1 hemisphere is damaged, the intact hemisphere may take over some of its functions.•To recover, the neurons needed to be stimulated through activity•Shown by functional MRI Scan studies on stroke patients

Five Basic Principles Five Basic Principles Governing NeuroplasticityGoverning Neuroplasticity

PRINCIPLE No. 3:SENSORY STIMULATION ENHANCES PLASTICITY!•Sensory stimulation enhances the sensory representation of the body part •It makes that area in the brain hyper-excitable to plasticity

Five Basic Principles Five Basic Principles Governing NeuroplasticityGoverning NeuroplasticityPRINCIPLE No. 4:REDUCTION OF INHIBITION ENHANCES PLASTICITY!•Remove factors that make the patient less motivated and sleepy!•Treat post-stroke depression but do not use drugs that induce drowsiness!

Five Basic Principles Five Basic Principles Governing NeuroplasticityGoverning NeuroplasticityPRINCIPLE No. 5:PHARMACOLOGIC AGENTS CAN ENHANCE PLASTICITY!

• in ischemic stroke, to reduce infarct site and promote repair and improve final functional outcome

•to improve neurological recovery after stroke

ManagementManagementPRINCIPLE No. 1:BODY PARTS COMPETE FOR BRAIN REPRESENTATION!•Ex: CIMT-constraint induced movement therapy

Constraint-Induced Constraint-Induced Movement Therapy Movement Therapy (CIMT)(CIMT)

Principle of FORCED USE to avoid the Learned Nonuse of the paretic side for Stroke patients

Mainly for training of upper extremity

CIMT and Cortical CIMT and Cortical ChangesChanges

• Cortical changes associated CIMT plus mental practice. Images reflecting the activations in 4 subtractions in patient 2. The top row of images depicts the sites of activation by subtracting the rest condition from the actual movement of the affected (right) hand condition (A) pretreatment (move affected > rest) and (B) posttreatment (move affected > rest). The second row depicts the sites from the subtraction of the rest from imagine moving the right hand condition both (C) pretreatment (imagine move affected > rest) and (D) posttreatment (imagine move affected > rest). Note (D) increased ipsilateral cortical activation. Shown are all activations that passed a criterion of P <.05 corrected for multiple comparisons with an extent threshold of 0.

pre post

ManagementManagementPRINCIPLE No. 2:THE IPSILATERAL & CONTRALATERAL HEMISPHERE CAN CONTRIBUTE TO MOTOR CONTROL!

• Mirror therapy

Mirror TherapyMirror Therapy

• Mirror Therapy (Mirror Visual Feedback)– form of motor

imagery in which a mirror is used to convey visual stimuli to the brain through observation of one's unaffected body part as it carries out a set of movements.

Mirror TherapyMirror Therapy• Mirror Therapy (Mirror

Visual Feedback)– Reflection of Movement

– a strategy that has been used successfully to treat phantom pain after amputation, may promote recovery from hemiplegia after a stroke

– The underlying principle is that movement of the affected limb can be stimulated via visual cues originating from the opposite side of the body.

– enhances recovery by enlisting direct visual stimulation showing the affected limb working properly, rather than relying on mental imagery alone.

– use movements of the stronger UE & LE to "trick our brain" into thinking that the weaker arm is moving

Mirror TherapyMirror Therapy

Mirror TherapyMirror Therapy TRAIN THE

BRAIN In a pilot study , fMRI

demonstrates that brain areas, that are involved in sensory-motor learning (mirror neurons), are activated by the visual illusion from mirror therapy.

ManagementManagementPRINCIPLE No. 3:SENSORY STIMULATION ENHANCES PLASTICITY!•Electrical stimulation/functional electrical stimulation•Stroking, massaging•Neuromuscular facilitation exercise techniques•Stimulate all the senses!

Management- Management- F E SF E SFunctional Electrical stimulation:•The most promising technique for hemiparetic arm!

GRIPPING DATA: Shows activity in the brain during repetitive gripping with the right hand. Each brain represents the activation pattern at different time points over the first six weeks after stroke for one patient.

Recovery of function is associated with diminishing brain activation, due to increasingly efficient neural circuitry.

This is very similar to what is seen during learning of a new complex motor task in the undamaged human brain

Management- Management- F E SF E S

•Functional Electrical stimulation

•IG STIMULATION-MOTOR RECRUITMENT

•RUSSIAN STIMULATION- MUSCLE STRENGTHENING AND MUSCLE RE-EDUCATION

Management- FESManagement- FES

•Functional Electrical stimulation

• Environmental Environmental simulationsimulation

• Verbal and Verbal and

• non-verbal non-verbal stimulationstimulation

ManagementManagement

Exercise Therapy Exercise Therapy

Neurodevelopmental techniques by Bobath•Stresses exercises that tend to normalize muscle tone and prevent excessive spasticity•Through special reflex-inhibiting postures & movementsIn beginning spasticity,•Slow, sustained stretching for spastic muscles•Vibration of antagonist muscles to reduce tone through reciprocal inhibition.

Exercise Therapy to Develop Exercise Therapy to Develop Motor ControlMotor Control

Facilitation techniques:1. Rood•involves superficial cutaneous stimulation using stroking, brushing, tapping & icing or vibration to evoke voluntary muscle activation2. Brunnstrom•Emphasized synergistic patterns* of movement that develop during recovery from hemiplegia•Encouraged the development of flexor & extensor synergies during early recovery, hoping that synergistic activation of muscle would, with training, transition into voluntary activation.* synergy-a whole series of muscles are recruited when just a few are needed

Exercise Therapy Exercise Therapy to to Develop Motor ControlDevelop Motor Control

Facilitation techniques:3. Kabat’s Proprioceptive Neuromuscular Facilitation (PNF)•Relies on quick stretching and manual resistance of muscle activation of the limbs in functional direction, which are often spiral and diagonal.

Exercise Therapy to Develop Exercise Therapy to Develop Motor Motor ControlControl

Facilitation techniques:Kabat’s Proprioceptive Neuromuscular Facilitation (PNF)

Exercise Therapy to Develop Exercise Therapy to Develop Motor ControlMotor Control

Conventional methods:•Stretching & strengthening•Attempting to retrain weak muscles through reeducation

ManagementManagementPRINCIPLE No. 4:

REDUCTION OF INHIBITION ENHANCES REDUCTION OF INHIBITION ENHANCES PLASTICITY!PLASTICITY!•Treat post-stroke depression and not use drugs that induce drowsiness!1.Individual psychotherapy- COUNSELLING.2.Positive reinforcement of the progress in rehab.3.Desipramine or Selective serotonin reuptake inhibitors (SSRI)-fluoxetine(PROZAC)

ManagementManagementPRINCIPLE No. 5:PHARMACOLOGIC AGENTS CAN ENHANCE PLASTICITY!

To improve neurological recovery after stroke

Management to induce Management to induce NeuroplasticityNeuroplasticity•All of the above five principles have to be translated into FUNCTIONAL TASK & CONTEXT-ORIENTED exercises!

REHAB TherapyREHAB Therapy for Early for Early PhasePhase

•Start as soon as the stroke is complete and vital signs are stable!•Usually within 48 hours.

Other Treatment for the Other Treatment for the Hemiparetic ArmHemiparetic Arm• EMG biofeedback

Wii Game and Wii Game and RehabilitationRehabilitation• Virtual Reality– VR is defined as an

approach to user-computer interface that involves real time stimulation of an environment, scenario or activity that allows for user interaction via multiple sensory channels.• Engaging &

Entertaining• Fun• (+) Visual and Auditory

Feedback from TV monitor

Management of MobilityManagement of MobilityConventional Physical Therapy:• Develop gross trunk control and training

in pregait activities such as posture, balance and weight transfer to the hemiparetic leg

• Once with strong synergies and spasticity, many will walk with a cane and ankle-foot orthosis (AFO)

Management of MobilityManagement of Mobility

Treadmill training with body weight support by a harness:

• The harness substitute for poor trunk control and the motor-driven treadmill forces locomotion.

• Therapists assist in controlling the trunk, pelvis and weak leg.

• It has been shown to be superior to conventional therapy!

• Some non-ambulatory hemiplegic patients learned to walk and those who were already walking significantly increased their gait speed.

Management- Management- Gait Gait TrainingTraining

Brain Imagery/ Mental Brain Imagery/ Mental PracticePracticeMental Practice Modify motor

performance

CNS creating a template of movement without activating motor plan

Activate descending corticospinal pathway, spinal cord and effector muscles

Repetitive Transcranial Repetitive Transcranial Magnetic Stimulation (rTMS)Magnetic Stimulation (rTMS)• Non invasive , deep

brain stimulation for motor cortex to enhance motor recovery

• Principle:• "It appears that

inhibitory and stimulatory rTMS may well prove useful tools in long-term programmes to rehabilitate stroke patients

---From European Journal of Neurology

Repetitive Transcranial Repetitive Transcranial Magnetic Stimulation ( PEMF)Magnetic Stimulation ( PEMF)

Important PointsImportant PointsRecovery in Stroke Depends on:• Location and extent of damange•Activation of secondary areas•Activation of contralateral areas

Important PointsImportant Points• “Neuroplasticity occurs better in motivated & moving patients”.

SummarySummary

• If a stroke patient is to recover, he must do (try) all of these activities by himself!!!