mengajar

1. Wisnu Prasetyo Adhi
PATOPHYSIOLOGY OF STROKE IN
PROVIDING PHYSIOTHERAPY
MUKADIMAH
Ya ALLAH SWT, beri aku kekuatan untuk mengubah hal-hal yang dapat
diubah, Rahmat dan kesabaran untuk menerima dengan ketenangan hal-
hal yang tidak dapat diubah, Dan berilah kebijaksanaan untuk
membedakan yang satu dari yang lain.
by Wisnu Prasetyo Adhi
RESTORATIVE NEUROLOGY
Restorative neurology is defines as the
branch of neurological sciences which
applies active procedures to improve
functions of the impaired nervous
system through selective structural or
functional modification of abnormal
neurocontrol according to underlying
mechanisms and clinically unrecognized
residual functions
(Hamburg WCON 1985)
USAHA NEURORESTORASI
Usaha Neurorestorasi : Cara terarah untuk membantu
pemulihan lesi dengan memanfaatkan mekanisme dasar
pemulihan sistem saraf.
(Harus mengetahui mekanisme pemulihan Lesi / perjalanan
sakit)
Lingkup Neurorestorasi
1. Aplied Neurofisiologi
2. Neuro biologi klinis
3. Fungsional Neurologi
Perhatian:Aspek medis (pato fisiologi) Fase akut ,
Kekhususan pada mekanisme selular dan molekular
biologi Neural repair

2. PENGARUH PADA TATA LAKSANA REHAB STROKE (TALLIS 1970)
➤ Pt stroke :“misguided” ~ “orthopaedic bias”
➤ Penanganan: massage, dipanaskan, gerak pasif, memakai
pulley, pemberat
➤ Hasilnya: kekakuan dan fleksi berlebihan tangan,
ekstensi kaki dan “foot drop”
➤ Nyeri bahu dan berachir dengan splint dan tongkat
(Ini dianggap konsekuensi stroke)
SEKILAS PERBEDAAN DENGAN REHABILITASI MEDIK
Rehabilitasi Medik
➤ 1923 American (College of Rad/Physiotherapy) – Am
Congress of Phys med: (penggunaan dan terapi dengan
modalitas fisika)
➤ 1966 Am Congress of Phys med (ACRM)
➤ Perhatian lebih pada disability = keterbatasan dan
handicap = ketunaan , social/psiko logical adjustment,
decubitus management, nyeri
➤ Dalam praktek pada aspek medis fase chronik/aging
➤ Kekhususan dalam “Organ Spesifik” sistem
MECHANISMS OF RECOVERY
➤ Mechanisms involved in recovery:
➤ Recovery of penumbral tissues
➤ Resolution of diaschises
➤ Behavioural compensation strategies
➤ Neuroplastic changes
Daffau, 2006
➤ Neurological rehabilitation is the management of
recovery
Gordon et al, 2005
MECHANISMS OF RECOVERY
➤ RECOVERY OF PENUMBRAL TISSUES

3. MECHANISMS OF RECOVERY - REVERSAL OF DIASCHISIS
Diaschisis: functional
changes in structures
remote from the site
of focal brain damage
➤ thalamic
hypometabolism
following a cortical
infarct
➤ cortical diaschisis
from a subcortical
infarct
➤ crossed cerebellar
diaschisis
MICROSCOPIC CHANGES - FUNCTIONAL
➤ Synaptic plasticity
➤ Modulation of synaptic strength and synchrony
➤ changes take place at the pre and post synaptic
terminals
➤ Long term potentiation/ Long term depression
➤ series of processes that lead to a durable increase
/ decrease in synaptic strength (hours → days)
➤ Unmasking of latent synapses
➤ Transformation of silent synapses to functional
synapses
MICROSCOPIC CHANGES - STRUCTURAL
➤ Dendritic spines: number, size and shape
➤ Axons: sprouting, regeneration and elongation
➤ Synaptogensesis: formation of new synapses
➤ Neurogenesis: neuronal replacement
➤ neurogenesis has been shown to occur in certain
locations in the adult brain
➤ ? role in recovery
DASAR KEJADIAN DIASCHISIS
➤ Respons alamiah akibat sistem “Net work” saraf.
➤ Terutama pada pusat yang bekerja-sama erat.
➤ Gangguan fungsi organ berlebihan.
➤ Dapat dibuktikan dengan neuroimaging atau EEG
berulang.

4. ASPEK PENTING DIASCHISIS (VON MONAKOW)
➤ Umumnya daerah yang terkena diaschisis
berhubungan secara anatomi dan fungsional dengan
lesi akut serta bersifat tiba-tiba.
➤ Mekanisme: hilangnya eksitasi
➤ Potensial untuk reversibel/menghilang seca- ra
bertahap = mekanisme perbaikan aktif.
➤ Gelombang diaschisis mengikuti perjalanan neuro-
anatomi : kortiko-spinal, komisura dan asosiasi.
Bersamaan tapi umumnya satu mendominasi
TIME
PTS STROKE
ACTIVATION
0 VII XII
DIASCHISIS
CONTROL
NORMALITATION
177 396
| | |
|
Hyperactivation
Process of restoring diaschisis(Dynamic)
Frackowiak 2006, Goteborg
EVALUASI TERHADAP FENOMENA DIASCHISIS
➤ Fenomena yang selalu ada mengikuti kejadian lesi
akut
➤ Merupakan “neural model” yang tidak sepenuhnya
dimengerti
➤ Pada perbaikan jangka panjang harus ada mekanisme
lain (plastisitas?)
➤ ( Paul BachY Rita -1987)
PLASTISITAS
➤1906 Ernesto Lugano: Neuron berinteraksi
dengan Environment ( lingkungan), aktivitas
dan aktivitas berfikir
➤1950. Donald Hebb: Koneksi antar neuron
kortikal berubah dan dapat diperbaharui
(“remodeled”) dengan pengalaman

5. PLASTISITAS
➤Kapasitas susunan saraf pusat- beradaptasi thd
kebutuhan fungsional:
Sebagai sistem = berorganisasi
Jelas pada periode perkembangan , tapi otak
dewasa masih memp. plastisitas: belajar
ketrampilan baru, mengingat, berespons thd lesi
selama hidup.
PLASTICITY
Solid
Elastic
Plastic
Before During After
STRUKTUR NEURON
➤ Pewarnaan “silver salt” Golgi
➤ 1800 Santiago Ramon y Cahal
➤ Neuron: tidak continue tapi
membentuk “Network” =
jaringan dengan neuron lain
➤ Otak bukan kelenjar
NEUROPLASTICITY
• Plastisitas adalah istilah yang digunakan untuk menggambarkan
perubahan neurobiologis dalam struktur dan fungsi sistem
saraf pusat (SSP) dewasa sebagai respons terhadap berbagai
rangsangan internal (misalnya patofisiologi) dan eksternal
(misalnya exercise).
• Kemampuan dari jaringan saraf orang dewasa ini diyakini
menjadi dasar untuk pembelajaran di otak yang normal dan
pemulihan setelah kerusakan otak (Kleim dan Jones,
2008).

6. NEUROPLASTICITY
ž Suatu konsep dasar mengenai kemampuan
CNS utk beradaptasi, membangun dan
menata ulang dirinya sendiri (baik secara
molekular, anatomi dan fungsi)
ž Anatomis (Struktur) Fisiologi (Fungsi)
ž Fisiologi (Fungsi) Anatomi (Struktur)
Kleim & Jones 2008
Synaptic Plasticity
(Structural)
PRE SYNAPTIC SITE
Long term change
Nucleus of the post-
synaptic cell forms
new proteins:
→insertion of new
receptors
→insertion of new
membrane
(Lawes, 1995)
A
B
C
DI LEVEL PLASTICITAS MANA FISIOTERAPI????? MACROSCOPIC CHANGES
IMAGING EVIDENCE IN HUMANS
Rossini et al, 2003

7. NEURAL PLASTICITY TIMELINE
Adkins et al, 2006; p1778
Predictive
Onset
TrA
Onset
deltoid
Deltoid
TrA
OI
OE
RA
ES
RA
OE
50 ms
OI
TrA
Hodges & Richardson, 1997 Exp Brain Res
KOMUNIKASI ANTAR NEURON
PADA KORTEKS TIDAK RANDOM TAPI DENGAN
KONEKSI YANG KHUSUS
POLA / PATTERN
➤ Pola kerjasama antar neuron
pada skilled normal
movement
➤ Terdapat koneksi yang
“silent”
Hippocampus, 2003

8. LESI FUNGSIONAL MOTORIK AKIBAT GGN EFEKTIFITAS SILENT SYNAPS
➤ Lesi ! Blok fisiologis
! kerja sinaps = ? :
➤ Super sensitivity : pd
post sinaps
➤ !“Silent” sinaps : fungsi
(-)/ab(N) "!
kompetisi
➤ Renegerative/ reactive
sinaptogesis
FENOMENA KONEKSI SINAPS
“TABULA RASA”
➤ Untuk neuron sinaps motorik + 50000 kebanyakan ‘silence’
H.Markram, Repair in the blue brain spic, Closing lecture WFNR Vienna 2010
NEURORESTORASI - PLASTISITAS
➤ “recovery” lesi dg memanfaatkan mekanisme dasar pemulihan
sistem saraf
➤ otak selalu berubah (changing) sbg respons thd:
➤ pengalaman
➤ pembelajaran -----------plastisitas
➤ pemulihan
➤ “Researcher” dari Max Planck Institute:
➤ We never use the same brain twice
THERAPY AND PLASTICITY
AIMS
➤ Strengthen synaptic chains and neuronal sets that
enhance motor control
➤ Guide axonal sprouting
➤ Facilitate unmasking of alternative, previously
subservient pathways to regain normal function
through alternative routes

9. THERAPY AND PLASTICITY
ž BELOW - UP
¡ Sensory/motor (use) meningkatkan S/M
representasi (maping) pada cortex
ž TOP - DOWN
¡ Cortex mengubah subcortical (eg.thalamus,
hypocampus, ex)
ž CROSS – SYSTEM
¡ sensory input menghasilkan perubahan pada
cortex motorik (ascenden-----descenden)
EXPERIENCE / SKILL memunculkan PLASTICITY
LESI Menyebabkan PLASTICITY
THERAPY AND PLASTICITY
Behavioural Compensation Strategies
➤ Development of compensatory behaviours to
perform activities and subsequent brain re-
organisation
Kleim and Jones, 2008
➤ Motor learning can impede recovery through the
development of compensations
Cirstea & Levin, 2007;
Michaelsen & Dannenbaum, 2006)
➤ Neurological or musculoskeletal lesion leads to altered
anatomy – form
➤ CNS adapts to altered anatomy to produce movement –
function
➤ How goals are achieved will change the form of the
CNS
➤ Towards more efficient or less efficient movement?
FORM / FUNCTION 3 PHASES OF LEARNING
➤ Verbal – cognitive phase
➤ Tasks new to learner, lots of cognitive effort, poor
performance
➤ Motor associative phase
➤ Reduced self talk, most problems solved, performance
becomes more stable and consistent
➤ Automatic phase
➤ Actions are automatic after much practice, now able to
think of other things while performing task

10. BRAIN ACTIVITY DURING LEARNING PHASE
Early : sens-motor cortex
primari, asc, supl, pre
dll
Learned skill
• Only primary,
cerebellum and
striatum
UNDERSTANDING A TASK
Ê Verbal Information
Ê Commands, explanations
Ê verbal cueing
Ê Showing and copying
Ê Imitation of the
movement
Ê Learning the movement
on the other side of the
body
Ê Pictures, photos, video
Ê Facilitation
Ê Analysis and specific
application of sensory
information
Ê Self experience
Ê Experimenting
Ê Awareness
Ê Feedback
Ê extrinsic
Ê intinsic
KETERAMPILAN PEMBELAJARAN MOTORIK
Reaching Task
NORMAL FUNCTIONAL MOVEMENT
Characteristic of normal movement

11. WHAT IS NORMAL MOVEMENT?
Characteristics: - Goal directed
- Effortless - Efficient
- Fluid - Smooth
- Skillfull - Innate
CIRI PENANGANAN NEURO RESTORASI
➤ Pendekatan multidisiplin terpadu – contoh Unit Stroke
➤ Sesuai dengan patofisiologi – mempertimbangkan
neuroanatomi dan neurofisiologi
➤ Bersifat stimulasi sistem saraf, normal fungsional
movement
➤ Penanganan ditujukan kesistem saraf bukan organ
STIMULASI
➤ Kunci “use it or lose it, Stimulate it or lose it”.
➤ stimulasi dapat dari afferent atau langsung dari
environment,
➤ Dalam memberikan stimulasi yang efisien
pertimbangkan: anatomi , faal dan intervensi obat2an
➤ anatomi jalur ventromedial adan dorsolateral
➤ adanya mekanisme sinergi dan silent sinaps
Correction of motor control “faults”
Posture
Movement
Muscle activation
Breathing issues
Continence/other
pelvic floor issues
Beliefs &
attitudes
Optimization of motor
control
Static progression
Static control of
lumbopelvic
orientation/alignment
Optimization of motor
control
Dynamic progression
Dynamic control
of lumbopelvic
orientation/alignment &
movement
Adjacent regions
Sensory function
Balance issues
Muscle strength
& endurance
Functional re - education
Specific to patient goals Fitness

12. BREAATHING ISSUES IN STROKE PATIENTS Movement: Assessment
FUNCTIONAL NEUROSCIENCE ICF FRAME WORK
BIO-PSYCHOSOCIAL Factor

13. BRAIN & CNS FUNCTION RECEIVING INFORMATION SENSORY SYSTEM
For normal MOVEMENT we need to:
Receive
information from senses
Integrate
information with memory and stored knowledge
Monitor and correct
action and behaviour in response to changes in
environment
POST STROKE CARE
TAHAPAN
POSTSTROKECARE
Hypothetical pattern of
recovery after stroke in
humans (with timing of
intervention strategies).
The greater part of recovery
is reported to take place in
the first three months
following stroke.
Rehabilitation interventions
targeting at improving a
stroke patients' performance
should be implemented
according to the phase of
neurological recovery.

14. STROKE ONSET TIME COURSE OF STROKE RECOVERY
Time course of post strokerecovery
• Cell death
• Metabolic depression: an adaptive biological process
for energy preservation.
• Axonal growth inhibition: ‘RhoA and Rho-kinase
activity -- Myelin-derived neurite outgrowth inhibitors’.
• Gliogenesis: the developmental process by which glial
cells – astrocytes, oligodendrocytes, Schwann cells,
microglia.
• Angiogenesis: the physiological process through
which new blood vessels form from pre-existing
vessels, formed in the earlier stage of
vasculogenesis.
• Neurogenesis: the process by which new neurons
are formed in the brain.
• Functional plasticity – use dependent plasticity:
The brain's ability to move functions from a
damaged area of the brain to other undamaged
areas.
• Axonal sprouting – Synaptogenesis
THERAPEUTIC STRATEGIES EARLY PHYSIOTHERAPY FOR STROKE
StrokeTherapyand Exercise:Move EarlyandOften
to IncreaseFunction*..JURNALEARL
YREHABILIT
ATION-
STROKESTROKEAHA.107.492363.pdf !!! The American Heart Guideline on acute stroke

15. “TERIMA KASIH
Wisnu Prasetyo Adhi