Neuro stroke rehabilitation


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  • Dear Dr. Das - nice presentation. If you /anybody else would like to join me in voluntary efforts towards stroke awareness and support in India, please contact me via . Thank you.
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Neuro stroke rehabilitation

  2. 2. Neuro Rehabilitation <ul><li>Definition: </li></ul><ul><li>“ A process whereby patients who suffer </li></ul><ul><li>from impairment following neurologic </li></ul><ul><li>diseases regain their former abilities or, if full recovery is not possible, achieve </li></ul><ul><li>their optimum physical, mental, social and vocational capacity.” </li></ul>WELLNESS RX REHABILITATION SERVICE
  3. 3. Neuro Rehabilitation Definition: 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
  4. 4. Common words used in Rehabilitation <ul><li>Impairment -refer to the loss of structures </li></ul><ul><li>or function </li></ul><ul><li>Disability -refer to limitations or </li></ul><ul><li>restrictions resulting from the </li></ul><ul><li>impairments </li></ul><ul><li>Handicap -refer to the inability to perform </li></ul><ul><li>social/vocational functions resulting from </li></ul><ul><li>impairment </li></ul>
  5. 5. Neuroplasticity/Brain Plasticity <ul><li>Definition: </li></ul><ul><li>The capability of the brain (or the CNS) to reorganize by forming new neural connections throughout life. </li></ul><ul><li>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 . </li></ul>REHAB is a process of healing from within !!
  6. 6. Cerebral Stroke <ul><li>Demographics: </li></ul><ul><li>Leading cause of disability! </li></ul><ul><li>15M stroke cases/year </li></ul><ul><li>worldwide </li></ul><ul><li>5M die </li></ul><ul><li>5M permanently disabled </li></ul><ul><li>Overall mortality is declining </li></ul><ul><li>Long-term survival post-stroke is improving </li></ul>
  7. 7. Five Basic Principles Governing Neuroplasticity <ul><li>PRINCIPLE No. 1: </li></ul><ul><li>BODY PARTS COMPETE FOR </li></ul><ul><li>BRAIN REPRESENTATION! </li></ul><ul><li>“ Use dependent plasticity” > “experience dependent </li></ul><ul><li>plasticity” </li></ul><ul><li>“ There is a need for the brain to use experience to </li></ul><ul><li>initiate a new synaptic connection between neurons” </li></ul><ul><li>“ the more a part is used the bigger its area of </li></ul><ul><li>representation in the brain that correlates with </li></ul><ul><li>improved function” </li></ul><ul><li>Opposite effect is “learned non use” </li></ul>
  8. 8. Five Basic Principles Governing Neuroplasticity <ul><li>PRINCIPLE No. 2: </li></ul><ul><li>THE IPSILATERAL & </li></ul><ul><li>CONTRALATERAL HEMISPHERE </li></ul><ul><li>CAN CONTRIBUTE TO MOTOR CONTROL! </li></ul><ul><li>If 1 hemisphere is damaged, the intact </li></ul><ul><li>hemisphere may take over some of its </li></ul><ul><li>functions. </li></ul><ul><li>To recover, the neurons needed to be stimulated through activity </li></ul><ul><li>Shown by functional MRI Scan studies on </li></ul><ul><li>stroke patients </li></ul>
  9. 9. Five Basic Principles Governing Neuroplasticity <ul><li>PRINCIPLE No. 3 : </li></ul><ul><li>SENSORY STIMULATION </li></ul><ul><li>ENHANCES PLASTICITY! </li></ul><ul><li>Sensory stimulation enhances the sensory </li></ul><ul><li>representation of the body part </li></ul><ul><li>It makes that area in the brain hyper-excitable to </li></ul><ul><li>plasticity </li></ul>
  10. 10. Five Basic Principles Governing Neuroplasticity <ul><li>PRINCIPLE No. 4 : </li></ul><ul><li>REDUCTION OF INHIBITION ENHANCES PLASTICITY! </li></ul><ul><li>Remove factors that make the patient less </li></ul><ul><li>motivated and sleepy! </li></ul><ul><li>Treat post-stroke depression but do not use </li></ul><ul><li>drugs that induce drowsiness! </li></ul>
  11. 11. Five Basic Principles Governing Neuroplasticity <ul><li>PRINCIPLE No. 5: </li></ul><ul><li>PHARMACOLOGIC AGENTS CAN ENHANCE PLASTICITY! </li></ul><ul><li>in ischemic stroke, to reduce infarct site and </li></ul><ul><li>promote repair and improve final functional </li></ul><ul><li>outcome </li></ul><ul><li>to improve neurological recovery after stroke </li></ul>
  12. 12. Management <ul><li>PRINCIPLE No. 1: </li></ul><ul><li>BODY PARTS COMPETE FOR BRAIN REPRESENTATION! </li></ul><ul><li>Ex: CIMT-constraint induced movement therapy </li></ul>
  13. 13. Constraint-Induced Movement Therapy (CIMT) <ul><li>Principle of FORCED USE to avoid the Learned Nonuse of the paretic side for Stroke patients </li></ul><ul><li>Mainly for training of upper extremity </li></ul>
  14. 14. CIMT and Cortical Changes <ul><li>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. </li></ul>pre post
  15. 15. Management <ul><li>PRINCIPLE No. 2: </li></ul><ul><li>THE IPSILATERAL & CONTRALATERAL HEMISPHERE CAN CONTRIBUTE TO MOTOR CONTROL! </li></ul><ul><li>Mirror therapy </li></ul>
  16. 16. Mirror Therapy <ul><li>Mirror Therapy (Mirror Visual Feedback) </li></ul><ul><ul><li>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. </li></ul></ul>
  17. 17. Mirror Therapy <ul><li>Mirror Therapy (Mirror Visual Feedback) </li></ul><ul><ul><ul><li>Reflection of Movement </li></ul></ul></ul><ul><ul><li>a strategy that has been used successfully to treat phantom pain after amputation, may promote recovery from hemiplegia after a stroke </li></ul></ul><ul><ul><li>The underlying principle is that movement of the affected limb can be stimulated via visual cues originating from the opposite side of the body. </li></ul></ul><ul><ul><li>enhances recovery by enlisting direct visual stimulation showing the affected limb working properly, rather than relying on mental imagery alone. </li></ul></ul><ul><ul><li>use movements of the stronger UE & LE to &quot;trick our brain&quot; into thinking that the weaker arm is moving </li></ul></ul>
  18. 18. Mirror Therapy
  19. 19. Mirror Therapy <ul><li>  </li></ul><ul><li>TRAIN THE BRAIN </li></ul><ul><li>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. </li></ul>
  20. 20. Management <ul><li>PRINCIPLE No. 3 : </li></ul><ul><li>SENSORY STIMULATION ENHANCES PLASTICITY! </li></ul><ul><li>Electrical stimulation/functional electrical </li></ul><ul><li>stimulation </li></ul><ul><li>Stroking, massaging </li></ul><ul><li>Neuromuscular facilitation exercise techniques </li></ul><ul><li>Stimulate all the senses! </li></ul>
  21. 21. Management- F E S <ul><li>Functional Electrical stimulation: </li></ul><ul><li>The most promising technique for hemiparetic arm! </li></ul><ul><li>GRIPPING DATA:  </li></ul><ul><ul><li>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. </li></ul></ul><ul><ul><ul><li>Recovery of function is associated with diminishing brain activation, due to increasingly efficient neural circuitry. </li></ul></ul></ul><ul><ul><li>This is very similar to what is seen during learning of a new complex motor task in the undamaged human brain </li></ul></ul>
  22. 22. Management- F E S <ul><li>Functional Electrical stimulation </li></ul><ul><li>IG STIMULATION- </li></ul><ul><li>MOTOR RECRUITMENT </li></ul><ul><li>RUSSIAN STIMULATION- MUSCLE STRENGTHENING AND MUSCLE RE-EDUCATION </li></ul>
  23. 23. Management- FES <ul><li>Functional Electrical stimulation </li></ul>
  24. 24. <ul><li>Environmental simulation </li></ul><ul><li>Verbal and </li></ul><ul><li>non-verbal stimulation </li></ul>Management
  25. 25. Exercise Therapy <ul><li>Neurodevelopmental techniques by Bobath </li></ul><ul><li>Stresses exercises that tend to normalize </li></ul><ul><li>muscle tone and prevent excessive spasticity </li></ul><ul><li>Through special reflex-inhibiting postures & </li></ul><ul><li>movements </li></ul><ul><li>In beginning spasticity, </li></ul><ul><li>Slow, sustained stretching for spastic muscles </li></ul><ul><li>Vibration of antagonist muscles to reduce tone </li></ul><ul><li>through reciprocal inhibition. </li></ul>
  26. 26. Exercise Therapy to Develop Motor Control <ul><li>Facilitation techniques: </li></ul><ul><li>1. Rood </li></ul><ul><li>involves superficial cutaneous stimulation using stroking, brushing, tapping & icing or vibration to evoke voluntary muscle activation </li></ul><ul><li>2. Brunnstrom </li></ul><ul><li>Emphasized synergistic patterns* of movement that develop during recovery from hemiplegia </li></ul><ul><li>Encouraged the development of flexor & extensor synergies during early recovery, hoping that synergistic activation of muscle would, with training, transition into voluntary activation. </li></ul><ul><li>* synergy-a whole series of muscles are recruited when just a few are needed </li></ul>
  27. 27. Exercise Therapy to Develop Motor Control <ul><li>Facilitation techniques: </li></ul><ul><li>3. Kabat’s Proprioceptive Neuromuscular Facilitation (PNF) </li></ul><ul><li>Relies on quick stretching and manual resistance of muscle activation of the limbs in functional direction, which are often spiral and diagonal . </li></ul>
  28. 28. Exercise Therapy to Develop Motor Control Facilitation techniques: Kabat’s Proprioceptive Neuromuscular Facilitation (PNF)
  29. 29. Exercise Therapy to Develop Motor Control <ul><li>Conventional methods: </li></ul><ul><li>Stretching & strengthening </li></ul><ul><li>Attempting to retrain weak muscles through </li></ul><ul><li>reeducation </li></ul>
  30. 30. Management <ul><li>PRINCIPLE No. 4 : </li></ul><ul><li>REDUCTION OF INHIBITION ENHANCES PLASTICITY! </li></ul><ul><li>Treat post-stroke depression and not use drugs </li></ul><ul><li>that induce drowsiness! </li></ul><ul><li>Individual psychotherapy- COUNSELLING. </li></ul><ul><li>Positive reinforcement of the progress in rehab. </li></ul><ul><li>Desipramine or Selective serotonin reuptake inhibitors (SSRI)-fluoxetine(PROZAC) </li></ul>TO BE TAKEN UNDER MEDICAL SUPERVISION
  31. 31. Management PRINCIPLE No. 5: PHARMACOLOGIC AGENTS CAN ENHANCE PLASTICITY! To improve neurological recovery after stroke TO BE TAKEN UNDER MEDICAL SUPERVISION
  32. 32. Management to induce Neuroplasticity <ul><li>All of the above five principles have to be translated into FUNCTIONAL TASK & CONTEXT-ORIENTED exercises! </li></ul>
  33. 33. REHAB Therapy for Early Phase <ul><li>Start as soon as the stroke is complete and vital </li></ul><ul><li>signs are stable! </li></ul><ul><li>Usually within 48 hours. </li></ul>
  34. 34. Other Treatment for the Hemiparetic Arm <ul><li>EMG biofeedback </li></ul>
  35. 35. Wii Game and Rehabilitation <ul><li>Virtual Reality </li></ul><ul><ul><li>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. </li></ul></ul><ul><ul><ul><li>Engaging & Entertaining </li></ul></ul></ul><ul><ul><ul><li>Fun </li></ul></ul></ul><ul><ul><ul><li>(+) Visual and Auditory Feedback from TV monitor </li></ul></ul></ul>
  36. 36. Management of Mobility <ul><li>Conventional Physical Therapy : </li></ul><ul><li>Develop gross trunk control and training in pregait activities such as posture, balance and weight transfer to the hemiparetic leg </li></ul><ul><li>Once with strong synergies and spasticity, many will walk with a cane and ankle-foot orthosis (AFO) </li></ul>MOBILITY FIRST & fast
  37. 37. Management of Mobility <ul><li>Treadmill training with body weight support by a harness: </li></ul><ul><li>The harness substitute for poor trunk control and the motor-driven treadmill forces locomotion. </li></ul><ul><li>Therapists assist in controlling the trunk, pelvis and weak leg. </li></ul><ul><li>It has been shown to be superior to conventional therapy! </li></ul><ul><li>Some non-ambulatory hemiplegic patients learned to walk and those who were already walking significantly increased their gait speed. </li></ul>
  38. 38. Management- Gait Training
  39. 39. Brain Imagery/ Mental Practice <ul><li>Mental Practice </li></ul><ul><li>Modify motor performance </li></ul><ul><li>CNS creating a template of movement without activating motor plan </li></ul><ul><li>Activate descending corticospinal pathway, spinal cord and effector muscles </li></ul>
  40. 40. Repetitive Transcranial Magnetic Stimulation (rTMS) <ul><li>Non invasive , deep brain stimulation for motor cortex to enhance motor recovery </li></ul><ul><li>Principle: </li></ul><ul><li>&quot;It appears that inhibitory and stimulatory rTMS may well prove useful tools in long-term programmes to rehabilitate stroke patients </li></ul><ul><li>---From European Journal of Neurology </li></ul>FIRST TIME IN HOOGHLY
  41. 41. Repetitive Transcranial Magnetic Stimulation ( PEMF) FIRST TIME IN HOOGHLY
  42. 42. Important Points <ul><li>Recovery in Stroke Depends on: </li></ul><ul><li>Location and extent of damange </li></ul><ul><li>Activation of secondary areas </li></ul><ul><li>Activation of contralateral areas </li></ul>TOTALITY
  43. 43. Important Points <ul><li>“ Neuroplasticity occurs better in </li></ul><ul><li>motivated & moving patients”. </li></ul>
  44. 44. Summary <ul><li>If a stroke patient is </li></ul><ul><li>to recover, he must </li></ul><ul><li>do (try) all of </li></ul><ul><li>these activities </li></ul><ul><li>by himself!!! </li></ul> SITTING CHARGES RS. 150-250/-