The term Spinal Cord Injury is used to refer to neurological damage of the spinal cord
Any lesion involving the spinal cord result a syndrome called a “myelopathy”
Spinal cord injuries are defined as complete or incomplete according to the International Standards for the Neurological Classifification of SCI and the American Spinal Injuries Association Impairment Scale (AIS)
Complete lesions are defifined as AIS A, and incomplete lesions are defifined as AIS B, AIS C, AIS D or AIS E (Harvey, 2016)
The term Spinal Cord Injury is used to refer to neurological damage of the spinal cord
Any lesion involving the spinal cord result a syndrome called a “myelopathy”
Spinal cord injuries are defined as complete or incomplete according to the International Standards for the Neurological Classifification of SCI and the American Spinal Injuries Association Impairment Scale (AIS)
Complete lesions are defifined as AIS A, and incomplete lesions are defifined as AIS B, AIS C, AIS D or AIS E (Harvey, 2016)
Stroke rehabilitation and its aspects to work with patients with hemiplegia and other effects of stroke, other than that you will see some pictures of the used interventions and adaptive equipment used with stroke patients
SYBPO - Orthotics.This presentation consists of all the pathological reasons affecting the lower extremity causing various deformities. it consists of Cerebral Palsy, polio, CDH etc.
n-172301.physiotherapy and clinical part of cerebellar ataxiapptAdyataDave
Acute cerebellar ataxia is sudden inability to coordinate muscle movement due to disease or injury to the cerebellum. This is the area in the brain that controls muscle movement. Ataxia means loss of muscle coordination, especially of the hands and legs.
Causes
Acute cerebellar ataxia in children, particularly younger than age 3, may occur several days or weeks after an illness caused by a virus.
Viral infections that may cause this include chickenpox, Coxsackie disease, Epstein-Barr, echovirus, among others.
Other causes of acute cerebellar ataxia include:
Abscess of the cerebellum
Alcohol, medicines, insecticides, and illicit drugs
Bleeding into the cerebellum
Multiple sclerosis
Strokes of the cerebellum
Vaccination
Trauma to head and neck
Certain diseases associated with some cancers (paraneoplastic disorders)
Symptoms
Ataxia may affect movement of the middle part of the body from the neck to the hip area (the trunk) or the arms and legs (limbs).
When the person is sitting, the body may move side-to-side, back-to-front, or both. Then the body quickly moves back to a sitting upright position.
When a person with ataxia of the arms reaches for an object, the hand may sway back and forth.
Common symptoms of ataxia include:
Clumsy speech pattern (dysarthria)
Repetitive eye movements (nystagmus)
Uncoordinated eye movements
Walking problems (unsteady gait) that can lead to falls
Difficulty controlling arm movements
Exams and Tests
The health care provider will ask if the person has recently been sick and will try to rule out any other causes of the problem. Brain and nervous system examination will be done to identify the most affected areas of the nervous system.
The following tests may be ordered:
CT scan of the head
MRI scan of the head
Spinal tap
Blood tests to detect infections caused by viruses or bacteria
Treatment
Treatment depends on the cause:
If the acute cerebellar ataxia is due to bleeding, surgery may be needed.
For an ischemic stroke, medicine to thin the blood can be given. Removing a blood clot from within the blood vessels may also be needed.
Infections may need to be treated with antibiotics or antivirals.
Corticosteroids may be needed for swelling (inflammation) of the cerebellum (such as from multiple sclerosis).
Cerebellar ataxia caused by a recent viral infection may not need treatment.
Physical therapy may be needed to reduce risk of falling.Outlook (Prognosis)
People whose condition was caused by a recent viral infection should make a full recovery without treatment in a few months. Strokes, bleeding, or infections may cause permanent symptoms.
Possible Complications
Falls may result in injury.
In rare cases, movement or behavioral disorders may persist.
When to Contact a Medical Professional
Contact your provider if any symptoms of ataxia appear.
Alternative Names
Cerebellar ataxia; Ataxia - acute cerebellar; Cerebellitis; Post-varicella acute cerebellar ataxia; PVACA
References
Kuo SH, Lin CC, Ashizawa T.
Stroke rehabilitation and its aspects to work with patients with hemiplegia and other effects of stroke, other than that you will see some pictures of the used interventions and adaptive equipment used with stroke patients
SYBPO - Orthotics.This presentation consists of all the pathological reasons affecting the lower extremity causing various deformities. it consists of Cerebral Palsy, polio, CDH etc.
n-172301.physiotherapy and clinical part of cerebellar ataxiapptAdyataDave
Acute cerebellar ataxia is sudden inability to coordinate muscle movement due to disease or injury to the cerebellum. This is the area in the brain that controls muscle movement. Ataxia means loss of muscle coordination, especially of the hands and legs.
Causes
Acute cerebellar ataxia in children, particularly younger than age 3, may occur several days or weeks after an illness caused by a virus.
Viral infections that may cause this include chickenpox, Coxsackie disease, Epstein-Barr, echovirus, among others.
Other causes of acute cerebellar ataxia include:
Abscess of the cerebellum
Alcohol, medicines, insecticides, and illicit drugs
Bleeding into the cerebellum
Multiple sclerosis
Strokes of the cerebellum
Vaccination
Trauma to head and neck
Certain diseases associated with some cancers (paraneoplastic disorders)
Symptoms
Ataxia may affect movement of the middle part of the body from the neck to the hip area (the trunk) or the arms and legs (limbs).
When the person is sitting, the body may move side-to-side, back-to-front, or both. Then the body quickly moves back to a sitting upright position.
When a person with ataxia of the arms reaches for an object, the hand may sway back and forth.
Common symptoms of ataxia include:
Clumsy speech pattern (dysarthria)
Repetitive eye movements (nystagmus)
Uncoordinated eye movements
Walking problems (unsteady gait) that can lead to falls
Difficulty controlling arm movements
Exams and Tests
The health care provider will ask if the person has recently been sick and will try to rule out any other causes of the problem. Brain and nervous system examination will be done to identify the most affected areas of the nervous system.
The following tests may be ordered:
CT scan of the head
MRI scan of the head
Spinal tap
Blood tests to detect infections caused by viruses or bacteria
Treatment
Treatment depends on the cause:
If the acute cerebellar ataxia is due to bleeding, surgery may be needed.
For an ischemic stroke, medicine to thin the blood can be given. Removing a blood clot from within the blood vessels may also be needed.
Infections may need to be treated with antibiotics or antivirals.
Corticosteroids may be needed for swelling (inflammation) of the cerebellum (such as from multiple sclerosis).
Cerebellar ataxia caused by a recent viral infection may not need treatment.
Physical therapy may be needed to reduce risk of falling.Outlook (Prognosis)
People whose condition was caused by a recent viral infection should make a full recovery without treatment in a few months. Strokes, bleeding, or infections may cause permanent symptoms.
Possible Complications
Falls may result in injury.
In rare cases, movement or behavioral disorders may persist.
When to Contact a Medical Professional
Contact your provider if any symptoms of ataxia appear.
Alternative Names
Cerebellar ataxia; Ataxia - acute cerebellar; Cerebellitis; Post-varicella acute cerebellar ataxia; PVACA
References
Kuo SH, Lin CC, Ashizawa T.
Similar to Sensory_Training_Presentation_2019_HO.pdf (20)
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
1. Sensory Training:
translating research to clinical practice & home program
Nel Ledesma, MHS, OTR/L
Rehabilitation Services
Beaumont Health System – Troy Campus
October 10, 2019
2. Course Objectives
• Discuss the prevalence of sensory impairment following a stroke
• Describe the stroke survivors’ experiences of sensory impairment in
the upper limb and impact with daily life
• Review sensory assessments and outcome measures
• Review the adaptive / compensatory strategies for sensory
impairment
• Discuss the passive and active sensory training
– Discuss the recommended parameters, electrodes placements and
dosage for passive sensory training using TENS
– Discuss Thermal Stimulation to improve thermal awareness
– Identify sample objects for active sensory training
• Describe sensory training home program
• Present case studies
2
3. Stroke Statistics
• Stroke kills about 140,000 Americans each year—that’s 1 out of
every 20 deaths.1
• Someone in the United States has a stroke every 40 seconds.
Every 4 minutes, someone dies of stroke.2
• Every year, more than 795,000 people in the United States have a
stroke. About 610,000 of these are first or new strokes.2
• About 185,00 strokes—nearly 1 of 4—are in people who have had a
previous stroke.2
• About 87% of all strokes are ischemic strokes, in which blood flow
to the brain is blocked.2
• Economic impact was estimated at $34 billion each year.2 This total
includes the cost of health care services, medicines to treat stroke,
and missed days of work.
3
4. Post stroke dysfunction
• Stroke is a leading cause of serious long-term
disability.2
• Sensation is commonly impaired after stroke
• Sensory impairments are associated with stroke
severity, decreased motor function, and are prognostic
factor for treatment outcomes 6,7,8
• Sensory deficits can prolong the duration of hospital
stay and negatively affect a person’s ability to use the
upper limb
4
5. Incidence of Sensory dysfunction
• Individuals with right hemisphere brain lesions
have been reported to have a higher incidence of
post stroke sensory dysfunction (37%) compared
with those with left hemisphere lesions (25%)8
• Damage to the parietal lobe (where the
somatosensory cortex is located) and damage to
the thalamus and brainstem (which relay sensory
information to the cortex) can cause sensation
issues. Sensory problems post stroke differ from
one person to another.
5
8. Parietal Lobe
• located near the center of the brain (upper middle lobe of each cerebral
hemisphere), behind the frontal lobe, in front of the occipital lobe, and
above the temporal lobe
• interprets sensory information, such as letting us know the location of
parts of our body and aiding in physical navigation
• integrates sensory information among various modalities, including spatial
sense and navigation (proprioception), the main sensory receptive area for
the sense of touch (mechanoreception) in the somatosensory cortex
• helps determine your own orientation in space, as well as the orientation
of other objects. It also receives significant input from the hand,
suggesting that it helps coordinate fine motor skills and sensory input
from the hands.
• functions in processing sensory information from the various parts of the
body. It is heavily related to the sense of touch and involved in the
manipulation of objects, as well as in detecting the orientation and
numbers of objects encountered. It is also an essential element of spatial
information, which gives us the ability to judge size, distance, and shapes.
8
9. Thalamus
• functions as an important relay and
integrative station for sensory signals and
motor information passing to all areas of
the cerebral cortex, the basal ganglia, the
hypothalamus, and the brainstem. It also
regulates consciousness, sleep and alertness.
9
10. Somatosensory system14
• Handles sensory input from superficial sources such as the
skin and deep sources such as musculoskeletal system
• Sensation is stimulated by receptors in the periphery of the
body and the sensory information travels to the brain by
way of the spinal cord
• Somatosensory receptors:
– Mechanoreceptors – respond to touch, pressure, stretch, &
vibration
– Chemoreceptors – respond to cell injury or damage
– Thermoreceptors – respond to heat or cold
• Each of these receptors has a subset called nociceptors
which sense pain when stimulated15
10
12. Major Ascending Pathways for the Somatic Senses
• Spinocerebellar: proprioception
from skeletal muscles to
cerebellum of same side (don’t
cross); large fibers
• Posterior (Dorsal) column:
discriminative touch sensation
through thalamus to
somatosensory cortex (cross in
medulla); large fibers
• Spinothalamic (Anterolateral):
carries non-discriminate
sensations through the thalamus
to the primary somatosensory
cortex (cross on spinal cord
before ascending); small fibers
12
14. Motor pathways
• Lateral pathway – voluntary control over skeletal muscles
– Lateral corticospinal tract – controls distal muscles
– Anterior corticospinal tract – controls proximal muscles
– Rubrospinal tract – control of muscle tone in flexor muscle group
• Anterior Medial pathway – muscle tone and gross movement of the
trunk (posture & balance) and proximal limb
– Vestibulospinal tract – maintain head and eye coordination, upright
posture and balance, and conscious realization of spatial orientation
and motion
– Reticulopsinal tract
– Tectospinal tract – coordinates head & eye movements
– Anterior corticospinal tract – controls proximal muscles
14
15. Frequency of sensory / somatosensory
impairment after stroke
• Connell, LA (2008)9
– 7–53% had impaired tactile sensations
– 31–89% impaired stereognosis
– 34–64% impaired proprioception
– Proprioception & stereognosis were more frequently impaired than
tactile sensations
• Carey, L & Matyas, T (2011)10
– 47% had touch discrimination impairment on affected hand
contralateral to the lesion & 16% experienced impairment on
ipsilesional “unaffected” hand
– 49% showed impaired limb position sense (proprioception) in the
affected limb & 20% on unaffected limb
• Concern has been expressed by authors about the validity of using
the uninvolved limb as the “normal reference” in testing because of
evidence of bilateral sensory impairment 8
15
16. Stroke Survivors’ self-reported experiences of
upper limb sensory impairments
Carlsson H, et.al. (2018) – qualitative study, 15
participants
• Changed & varied perception of sensation
• Affected movement control
• Problems using the upper limb (UL) in daily life
• Various strategies to cope with the upper limb
disability
• Lack of sensory training
16
17. Stroke Survivors’ self-reported experiences of
upper limb sensory impairments
Carlsson H, et.al. (2018) – qualitative study, 15 participants
• Changed & varied perception of sensation
– Numbness (fingertips were asleep similar to dental anesthesia), tingling,
burning sensation – some c/o UL was not alive, others reported feeling of
heaviness
– Changes in temperature sensitivity – sensitive to cold even if they wore gloves,
delay in perception of heat
– Increased sensitivity to touch & pain
• Affected movement control
– Difficulty adjusting the grip force – used too much pressure when holding or
manipulating objects because they were afraid of dropping; some reported
they had lost their automatic movements & had to increase their
concentration when holding or carrying task object resulting in increased
mental fatigue
– Proprioceptive & perceptual difficulties – difficulty performing smooth
movements w/precision, difficulty recognizing small objects with their hand
w/o vision or identifying an object in their pocket by touch alone
17
18. Stroke Survivors’ self-reported experiences of
upper limb sensory impairments
Carlsson H, et.al. (2018) – qualitative study, 15 participants
• Problems using the upper limb in daily life
– Personal care & dressing difficulties – such as washing hair, combing or styling hair, cutting
nails, brushing teeth, applying make up, putting earrings, tying shoelaces, managing fasteners
(buttons, zippers)
– Difficulty with cooking & eating – difficulty cracking an egg, cutting/chopping, whipping food
– Difficulty performing leisure activities – gardening, playing piano / tennis, applying brakes on a
bicycle, finding the safety belt
• Various strategies to cope with the upper limb disability
– Often use non-affected hand – lead to learned non-use of affected hand
– Compensate w/ vision
• Lack of sensory training
– Participants reported little attention was paid to their sensory impairment in IP & OP
rehabilitation
– Focus was on motor recovery
– No training program after discharge
18
19. Consequences of sensory loss
• At the risk of skin damage and burning due to loss or reduced
temperature sensation.
• With hypersensitivity to sensation, they may become over sensitive
to pain just by light touch or when moving. This may result in the
clothing being uncomfortable or even painful next to the skin.
• The loss of sensation from the bladder or bowel may lead to
incontinence problems.
• Paresthesia, an altered sensation such as numbness, tingling,
aching, burning or ‘pins and needles’ may cause great discomfort
and confusion.
• Proprioception (the loss or reduced ability to know where a body
part is) may make walking more difficult even if the muscle
movements are intact. They may not know when the foot is flat on
the floor or turned at the ankle joint.
• Movement lack precision and control.
19
20. Critical window for recovery
• Timeframe 3,4
– Acute: 1st month (offers the highest rate of recovery)5
– Sub-acute: 1 month to 6 months
– Chronic: > 6 months
• Initial days & weeks represent a critical window for therapeutic interventions to
maximize neurologic recovery of body functions & activities
• Recovery occurs through spontaneous neurologic process such as reperfusion
(return of blood supply) to tissue and reduction of swelling to minimize cortical
damage
• There is no clear picture of expected time period for recovery of sensory
impairments after stroke, one study suggested most recovery seems to occur in
the first 3 months, but some modalities (e.g. warm detection threshold, vibratory
detection threshold and two-point discrimination), recovery may continue
between 3 and 12 months 19,20
• Two other studies demonstrated recovery of sensation from time of stroke to
6 months 19,21
20
21. Lack of knowledge & training on evidence-based interventions
to effectively address sensory loss / dysfunction
• Despite high incidence of sensory impairments post-stroke, studies
of somatosensory retraining programs are limited
• Clinicians pay little attention to sensory retraining in stroke
rehabilitation
• Puppa LU, et.al. (2015) – have shown therapists reported barriers
– Lack of time and resources
– Limited knowledge of evidence-based interventions
– Focus was on motor recovery training
– Focus on compensatory strategies instead of remediation of sensory
impairments
• Education for therapists should focus on assessment of the sensory
impairment, meaningful goal-setting related to upper limb sensory
impairment, as well as providing specific sensory training 9,18
21
22. Evaluation of Sensation
• There is no widely accepted or standardized test of sensory
impairments after stroke 16
• Clinical descriptors such as “present”, “impaired”, or
“absent” are utilized
• Touch Sensation (Light Touch, Deep Pressure) - Semmes-
Weinstein Monofilaments
• Pain (protective sensation)
• Thermal / Temperature Awareness (protective sensation)
• Proprioception – Fugl Meyer 12,13
• Localization Touch
• Stereognosis
22
27. Secondary Outcome Measures
• Coordination
– Nine Hole Peg Test (NHPT)
– Box & Blocks Test (BBT)
• Pinch Strength
• Grip Strength
• ADLs/IADLs – tying shoelaces; managing fasteners
(buttons/zippers); putting on: belt, seat belt,
earrings; grasping task objects; cutting food, etc.
• Patient Specific Functional Scale (PSFS)
27
28. Sensory Re-education
• Sensory re-education is a technique therapists
use in attempt to retrain sensory pathways or
stimulate unused pathways.
• Therapists also teach adaptive techniques to
help compensate for sensory loss.
28
29. Adaptive or Compensatory Techniques25
• Use your vision to observe motion and location of body
parts.
• Avoid exposure of the involved limb to heat, cold, and
sharp objects (especially if the person is impulsive,
inattentive, or lacks safety awareness)
– Use your unaffected side to check temperature before
bathing or washing objects.
– Use your unaffected side to handle sharp objects &/or to
perform household management tasks such as cooking,
eating, and ironing
– Use adaptive devices such as one-handed cutting board
– Enlist the aid of caregivers to prepare hot meals
29
30. Adaptive or Compensatory Techniques cont.
25,26
• Adapt task objects / use built up handles on the
affected side to distribute pressure (the smaller the
handle the less distribution of pressure over the
gripping surfaces).
• Change positions frequently to prevent too much
pressure on affected area.
• Observe the skin for signs of stress (redness, edema,
warmth) from excessive force or repetitive pressure,
and rest the hand if these signs occur
• When gripping an object, don't apply more force than
is necessary.
30
31. Remediation of sensory loss /
dysfunction post-stroke
• Sensory training post-stroke can be divided into two
methods: 9,22
– Active sensory training - involves manual exploration of
different textures, figures, and objects with the hand and
fingers, and spatial detection of limb position
• Commonly prescribed sensory re-education techniques / exercises can
include touching different textured objects (finding objects w/o
looking, sensing how different objects feel), massage, vibration,
pressure, determining joint position, identifying different
temperatures, and sensory locating.
– Passive sensory training - involves the application of electrical
stimulation to produce activation of cutaneous nerves in
absence of muscle contraction.
• Thermal stimulation is the application of heating/cooling stimulant
31
32. Active sensory training25
• Try to differentiate between textures (i.e. cotton, sandpaper, satin,
velcro, rubber, velvet, wool, etc.)
• Hide objects such as marbles, coins, etc. in a bowl of rice/dry
beans/sand. Without using vision, try to find the objects with your
hand.
• Have another person touch you on one spot with your eyes open,
then with your eyes closed. Try to associate where you saw the
object touch your skin to know how it felt on your skin.
• Have another person keep pressure still on your skin then move it
around. Watch and pay attention to how it feels. Close eyes and try
to identify when the pressure is still versus when it is moving.
• Close your eyes and have a person apply vibration to your skin via a
massager. See if you can identify when the vibration is applied to
the skin. Have the person move the vibration around and see if you
can tell when it is still versus moving around on your skin.
32
33. Active sensory training cont.25
• Have someone place different objects in your hand while you are looking
(i.e. cotton ball, marble, key, paper clip). Close your eyes and then try to
identify objects as they are placed in your hand again one at a time.
• Fill a flexible paper cup (i.e. Dixie cup) half full with water. Attempt to
grasp cup without spilling the water or smashing the cup. Use your vision
to determine how much pressure you are putting on the cup (i.e. if cup is
slipping out of hand, apply more pressure; if cup is squeezed to hard,
lessen grip)
• Repeat exercise with paper cup above but now move the cup from one
spot to another maintaining a steady, even grasp (not too tight, not too
loose)
• Have another person apply cold and or warmth to your skin and see if you
can detect temperature differences.
• Feel an object then try to find a matching object inside a bowl of dry
beans or rice.
33
34. Active sensory training cont.25
• Close eyes and have someone else position your affected arm. See if you
can tell what position your arm is in (i.e. my elbow is bent) then open your
eyes to see what position it is in.
• Close eyes and have someone else place a lighter object on your hand
then a heavier object. Try to determine which object was heavier or
lighter.
• Block your vision or close eyes. Have someone else move your hand while
holding a pencil. Try to identify what letter, number or drawing is made.
34
37. Evidence-based studies to support use of TENS
in passive sensory training
• Schabrun SM & Hillier S (2009) – meta-analyses shows moderate
support for the effectiveness of passive sensory training in relation
to sensory impairment and improving dexterity & hand function
• Serrada I, Hordacre B & Hillier S (2019) – meta-analyses (13
comparisons, 385 participants) demonstrated moderate effect in
favor of passive sensory training on improving upper limb activity
following stroke
• Kita K, et.al. (2013) – A pilot study of sensory feedback by TENS to
improve manipulation deficit caused by severe sensory loss after
stroke
• Passive sensory training using electrical stimulation (TENS)
– has a high degree of clinical utility (readily available and cheap)
– is relatively risk free
– easy to implement when combined with active sensory training
(noninvasive intervention)
37
38. Passive sensory training using TENS
• Optimal stimulation parameters are yet to be
determined 23
– Mode – normal or continuous
– Monophasic rectangular pulse sequence
– Pulse Width (PW): 250 - 300 us
– Frequency (PR): 10 – 100 Hz
– Intensity - adjusted __ mA
– Treatment duration – 15 – 60 mins; 1-3x daily; 4-6 weeks
• Chipchase LS, Schabrun SM, Hodges PW (2011)24
– PR
50 Hz and PW 300 us are appropriate for activating skin
sensory sensation
38
39. Passive Sensory Training using TENS:
Electrodes Placement
Created by: Nel Ledesma, MHS, OTR/L
5/2017; revised 1.22.2019 39
Parameters: Mode _______; Pulse Width 250-300 us; Pulse Rate 50-100 Hz; Intensity ____ mA
Total treatment & frequency: _15 - 60__minutes; _1-3_ times per day; 4 to 6 weeks
One Pair of
Electrodes:
Base of the Neck
(Middle
Trapezius) on
same side –
Indifferent (Red)
Pad of the
Thumb / Index
Finger - Active
(Black)
Second Pair of
Electrodes:
Base of the Neck
(Middle Trapezius)
on R/L side –
Indifferent (Red)
Tip of the MF/RF/SF
– Active (Black)
40. Precaution when using TENS
• Patients with implanted electronic device such as a cardiac pacemaker,
implanted defribrillator, or any other metallic or electronic device should
not undergo TENS treatment without first consulting a doctor
• Patients with heart disease, epilepsy, cancer or any other health condition
should not undergo TENS treatment without first consulting a physician
• Electrical current of this magnitude must not flow through the thorax or
across the chest because it may cause a cardiac arrythmia
• Do not place electrodes on the front of the throat as spasm of the
laryngeal & pharyngeal muscle may occur.
• Stimulation over the carotid sinus (neck region) may close the airways,
make breathing difficult, and may have adverse effect on the heart rhythm
or blood pressure.
• Do not place electrodes on your head or any sites that may cause the
electrical current to flow transcerebrally (through the head)
40
41. Precaution when using TENS cont.
• The device should not be used while driving or operating
a machinery, close to water, or during any activity in
which involuntary muscle contractions may put the user
at undue risk or injury.
• Turn the TENS off before applying or removing the
electrodes.
• Isolated cases of skin irritation may occur at the site of
electrode placement following long term application.
• If TENS treatment becomes ineffective or unpleasant,
stimulation should be discontinued until its use is re-
evaluated by the therapist.
• Keep the device out of reach of children.
41
42. Case studies baseline (video)
42
• Janet M, 66 y.o.
• Dx: CVA w/ mild L
hemiparesis
• CT: subtle hyperacute
ischemic changes in
upper R frontal-parietal
junction w/ subtle edema
in the cortex & loss of
gray-white matter
interface junction
• Total visits: 15, seen
2x/wk
43. Case studies baseline (video)
43
• David K, 63 y.o.
• Dx: CVA w/ mild left
hemiparesis; s/p CAE
• CT: subacute ischemic
infarct R frontal lobe &
R temporal parietal
junction
• Total visits: 24, seen
3x/wk
47. Thermal Stimulation (TS)
47
Chen J-C, Liang C-C, Shaw F-Z (2005).
Facilitation of Sensory and Motor
Recovery by Thermal Intervention for
the Hemiplegic Upper Limb in Acute
Strokes Patients: A Single-Blind
Randomized Clinical Trial. Stroke
Materials needed:
• Heating pad or Water pad
(heating agent / stimulus) – set at
~ 160° F (75° C)
• Frozen Gel pack (cooling agent /
stimulus) - set at < 32° F (< 0° C)
• Towels & a pillow case
• Timer
48. Thermal Stimulation27
Instructions:
• Heating Agent Stimulation
– wrap the heating / water pad with 2 layers of towels
– place the involved/paretic _____ hand on the heating agent/stimuli for 10-15 seconds as shown by your
therapist (also place _____ hand as sensor to avoid tissue damage on involved hand), when unpleasantness
develops, reflexively pull hands off the heating agent/stimulus.
– Repeat 10x allowing 30 seconds pause in between repetition.
– After 10-time heating stimulation, allow the involved/paretic _____ hand to cool to body temperature
(~20 – 30 minutes) before starting the cooling agent/stimulus.
• Cooling Agent Stimulation
– wrap the frozen gel pack / cooling agent with 1 towel or a pillow case
– place the involved/paretic _____ hand on the cooling agent/stimuli for 30 seconds as shown by your
therapist, when unpleasantness develops, reflexively pull the hand off the heating agent/stimulus
– Repeat 10x allowing 30 seconds pause in between repetitions
• Perform two (2) cycles of heating and cooling stimulation once daily, 5x/week, for at least 6
weeks.
48
49. Case studies (videos)
49
• Riman S, 36 y.o.
• Dx: CVA w/mild right
hemiparesis
• CT: large
encephalomalacia (loss of
brain tissue) w/in L MCA
distribution consistent w/
h/o prior infarct
• Total visits: 15, seen
2x/wk
52. Sensory training using TENS
• Application to other diagnosis
– Guillain Barre’ Syndrome (GBS)
– Diabetic Peripheral Neuropathy (DPN)
– CIPN – Chemotherapy-Induced Peripheral Neuropathy
– MS
• Outcome Measure:
– Neuropathic Pain Questionnaire (NPQ)
– EORTC-CIPN20*
(* being evaluated)
52
53. Documentation
• Improve pinch strength & sensation on R hand to increase ease & independence in
tying shoelaces, managing fasteners (zipper, buttons) as rated by (Patient-Specific
Functional Scale) PSFS from 8-9/10 to 1-2/10
• Improve L pinch strength & proprioceptive sensation to increase ease in putting on
the seat belt w/o having to look at the hand as rated by PSFS from 10/10 to 1-2/10
or better
• Increase thermal awareness on R hand (from absent to diminished) so patient can
safely check water temperature when washing dishes, hands or bathing as rated
by PSFS from 10/10 to 0/10
• Improve touch sensation & calibration of grasp on L hand so patient can effectively
grasp a paper/styrofoam cup w/o spilling and/or maintain hold on a water bottle
w/o slipping off his/her fingers as rated by PSFS from 9/10 to 1-2/10 or better
• Increase R pinch strength by 2-3# or > so patient can effectively use a nail clipper
• Improve sensation & coordination on R hand as evidenced by decreased time to
complete NHPT from 121 secs to 60 secs or <
• Decrease neuropathic pain as evidenced by diminished NPQ score from 3.184 to
zero or below
53
56. Summary / Clinical message
• With high incidence of sensory dysfunction
post-stroke, OTs should evaluate & address
the sensory impairments
• There is a growing evidence to support
sensory-focused interventions worldwide
• Moderate evidence exists to support passive
sensory training using TENS to improve hand
function and dexterity following stroke
56
58. References
1. Vital Signs: Recent trends in stroke death rates – United States, 2000-2015. MMWR
2017;66.
2. Benjamin EJ, Blaha MJ, Chiuve SE, et al. on behalf of the American Heart Association
Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke
statistics—2017 update: a report from the American Heart Association. Circulation.
2017;135:e229-e445.
3. Teasell, R. W., Murie Fernandez, M., McIntyre, A., and Mehta, S. (2014). Rethinking the
continuum of stroke rehabilitation. Arch. Phys. Med. Rehabil. 95, 595–596. doi:
10.1016/j.apmr.2013.11.014
4. Hebert, D., Lindsay, M. P., McIntyre, A., Kirton, A., Rumney, P. G., Bagg, S., et al. (2016).
Canadian stroke best practice recommendations: stroke rehabilitation -practice guidelines,
update 2015. Int. J. Stroke 11, 459–484. doi: 10.1177/1747493016643553
5. Buma F, Kwakkel G, Ramsey N (2013) Understanding upper limb recovery after stroke,
Restor Neurol Neurosci; 31: 707-22
6. Connell, LA (2008). Somatosensory impairment after stroke: frequency of different deficits
and their recovery. Clinical Rehabilitation, 22: 758–767
58
59. References
7. Patel AT, Duncan PW, et.al. (2000). The relation between impairments &
functional outcomes poststroke. Archives of Physical Medicine & Rehabilitation,
81: 1357-1363
8. Sullivan JE & Hedman LD (2008). Sensory dysfunction following stroke: incidence,
significance, examination, & intervention. Topics of Stroke Rehabilitation, 15: 200
- 217
9. Carlsson H, Gard G, & Brogardh C (2018). Upper-Limb sensory impairments after
stroke: self-reported experiences of daily life & rehabilitation. Journal of
Rehabilitation Medicine, 50: 45-51
10. Carey L & Matyas T (2011). Frequency of sensory discriminative loss in the hand
after stroke in a rehabilitation setting. Journal of Rehabilitation Medicine, 43:
257-263
11. Holmgren H, et.al. (1990). Central post stroke pain – somatosensory evoked
potentials in relation to location of the lesion and sensory signs. Pain 40(1): 43-
52
12. Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S. (1975). The post-stroke
hemiplegic patient: a method for evaluation of physical performance. Scand J
Rehabil Med, 7:13-31
59
60. References
13. Fugl-Meyer AR. (1980). Post-stroke hemiplegia assessment of physical
properties. Scand J Rehabil Med, 7(Suppl): 85-93
14. Pendleton HM & Schultz-Krohn W (Editors). Pedretti’s Occupational
Therapy: Practice Skills for Physical Dysfunction (7th edition), Elsevier, pp
575-589
15. Lundy-Ekman L (2007). Somatosensory system. In Lundy-Ekman L. editor:
Neuroscience: fundamentals for rehabilitation, ed 3, St. Louis, MO,
Saunders, pp 105-128
16. Connell LA, Tyson SF (2012). Measures of sensation in neurologic
conditions: a systematic review. Clinical Rehab, 26: 68-80
17. Bowden J, Lin G, McNulty P (2014). The prevalence & magnitude of
impaired cutaneous sensation across the hand in the chronic period
post-stroke. PLoS ONE 9(8): e104153. doi:10.1371/journal.pone.0104153
18. Pumpa LU, Cahill LS, Carey LM (2015). Somatosensory assessment &
treatment after stroke: an evidence-practice gap. Australian
Occupational Therapy Journal, 62: 93-104
60
61. References
19. Doyle S, Bennet S, Gustafsson L (2013). Occupational therapy for upper limb
post-stroke sensory impairments: a survey. British Journal of Occupational
Therapy, 76: 434-442
20. Julkunen L, et.al. (2005). Recovery of somatosensory deficits in acute stroke. Acta
Neurologica Scandinavica, 111: 366-372
21. Winward CE, Halligan PW, Wade DT (2007). Somatosensory recovery: a
longitudinal study of the first 6 months after unilateral stroke. Disability
Rehabilitation, 29: 293-299
22. Schabrun SM & Hillier S (2009). Evidence for the retraining of sensation after
stroke: a systematic review. Clinical Rehabilitation, 23: 27-39
23. Kita K et.al, (2013). A pilot study of sensory feedback by transcutaneous
electrical nerve stimulation to improve manipulation deficit caused by severe
sensory loss after stroke. Journal of NeuroEngineering and Rehabilitation, 10:55
24. Chipchase LS, Schabrun SM, Hodges PW (2011). Peripheral electrical stimulation
to induce cortical plasticity: a systematic review of stimulus parameters. Clinical
Neurophysiology, 122 (3): 456-463
61
62. References
25. www.stroke-rehab.com
26. Callahan AD (1995). Methods of compensation and reeducation
for sensory dysfunction. In Hunter JM, Mackin EJ, Callahan AD,
editors: Rehabilitation of the hand, ed 4, St. Louis, Mosby
27. Chen J-C, Liang C-C, Shaw F-Z (2005). Facilitation of Sensory and
Motor Recovery by Thermal Intervention for the Hemiplegic
Upper Limb in Acute Strokes Patients: A Single-Blind Randomized
Clinical Trial. Stroke, 2665-2669.
28. Krause SJ & Backonja MM (2003). Development of neuropathic
pain questionnaire. Clinical Journal of Pain, Sept-Oct; 19(5): 306-
314
29. Serrada I, Hordacre B, & Hillier S (2019). Does sensory retraining
improve sensation and sensorimotor function following stroke: A
systematic review and meta-analysis. Frontiers in Neuroscience,
April, Volume 13, Article 402
62
63. References
30. Lindsay TJ, Rodgers BC, Savath V, Hettinger K. (2010). Treating diabetic peripheral neuropathic
pain. Am Fam Physician. 82:151-158
31. Basbaum AI, Fields HL. (1978). Endogenous pain control mechanisms: review and hypothesis. Ann
Neurol. 4:451-462
32. Dubinsky RM, Miyasaki J (2010). Efficacy of transcutaneous electric nerve stimulation in the
treatment of pain in neurologic disorders (an evidence-based review): report of the Therapeutics
and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology;
74:173-176
33. Pieber K, Herceg M, Paternostro-Sluga T (2010). Electrotherapy for the treatment of painful
diabetic peripheral neuropathy: a review. J Rehabil Med.; 42:289–295
34. Jin DM, Yun X, Deng-Feng G, Tie-bin Y (2010). Effect of transcutaneous electrical nerve
stimulation on symptomatic diabetic peripheral neuropathy: a meta-analysis of randomized
controlled trials. Diabetes Res Clin Pract.; 89:10-15.
35. Jin DM, Xu Y, Geng DF, Yan TB (2010). Effect of transcutaneous electrical nerve stimulation on
symptomatic diabetic peripheral neuropathy: a meta-analysis of randomized controlled trials.
Diabetes Res. Clin. Pract. 89(1), 10–15
63