ASISH K DAS

WELLNESS RX PHYSIOTHERAPY CENTRE

NEURO REHABILITATION UNIT

www.akdwellnessrx.com
physioakd@gmail.com

response@akdwellnessrx.com
dasishkumar@yahoo.in

Neuro 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 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

Common words used in

Rehabilitation
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

Neuroplasticity/Brain
Plasticity

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 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

Governing 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

Five Basic Principles

Governing Neuroplasticity
PRINCIPLE 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

Governing 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 hyperexcitable to
plasticity

Five Basic Principles

Governing Neuroplasticity

PRINCIPLE 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

Governing Neuroplasticity
PRINCIPLE 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

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

Constraint-Induced
Movement Therapy
Principle of
(CIMT)

FORCED USE to
avoid the
Learned Nonuse
of the paretic
side for Stroke
patients
Mainly for
training of upper
extremity

CIMT and Cortical

Changes
pre

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 ofP<.05 corrected for
multiple comparisons with an
extent threshold of 0.

post

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

Mirror therapy

Mirror 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 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 Therapy

Mirror 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.

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

Management- F E S
Functional 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- F E S

Functional

IG

Electrical stimulation

STIMULATION-

MOTOR RECRUITMENT

RUSSIAN

STIMULATION-

MUSCLE STRENGTHENING AND MUSCLE REEDUCATION

Management- FES
Functional

Electrical stimulation

Management
Environmental
simulation
Verbal and
non-verbal
stimulation

Exercise Therapy
Neurodevelopmental techniques by
Bobath
Stresses exercises that tend to normalize
muscle tone and prevent excessive
spasticity
Through special reflex-inhibiting postures
&
movements
In beginning spasticity,
Slow, sustained stretching for spastic
muscles
Vibration of antagonist muscles to reduce

Exercise Therapy to Develop

Motor Control

Facilitation techniques:
1. Rood
involves superficial cutaneous stimulation
using stroking, brushing, tapping & icing or
vibration to evoke voluntary muscle activation
2. 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
to Develop Motor Control
Facilitation techniques:
3. Kabats 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

Motor Control
Facilitation techniques:
Kabats Proprioceptive Neuromuscular
Facilitation (PNF)

Exercise Therapy to Develop

Motor Control

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

Management
PRINCIPLE No. 4:
REDUCTION OF INHIBITION ENHANCES
PLASTICITY!
Treat post-stroke depression and not use
drugs
that induce drowsiness!
1.Individual psychotherapyCOUNSELLING.
2.Positive reinforcement of the progress in
rehab.
3.Desipramine or Selective serotonin
reuptake inhibitors (SSRI)fluoxetine(PROZAC)

Management
PRINCIPLE No. 5:
PHARMACOLOGIC AGENTS CAN
ENHANCE PLASTICITY!
To improve neurological recovery after
stroke

Management to induce
Neuroplasticity
All

of the above five principles have to be

translated into FUNCTIONAL TASK &
CONTEXT-ORIENTED exercises!

REHAB Therapy for Early

Phase

Start

as soon as the stroke is complete

and vital
signs are stable!
Usually within 48 hours.

Other Treatment for the

Hemiparetic
Arm

EMG biofeedback

Wii Game and

Rehabilitation

Virtual Reality

VR is defined as an
approach to usercomputer 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 Mobility
Conventional 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 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.

ManagementGait Training

Brain Imagery/ Mental

Practice
Mental

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
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
Magnetic Stimulation ( PEMF)

Important Points
Recovery in Stroke Depends on:
Location and extent of damange
Activation of secondary areas
Activation of contralateral areas

Important Points
Neuroplasticity occurs better in

motivated & moving patients.

Summary

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