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
impairment
 Neuroplasticity/Brain Plasticity
Definition:

•The capability of the brain

(or the CNS) to reorganize
by forming new neural
connections throughout life.

•Itallows 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 with
improved function”
•Opposite effect is “learned non use”
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 hyper-excitable 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 stroke

 Management
PRINCIPLE No. 1:
BODY PARTS COMPETE FOR BRAIN
REPRESENTATION!
•Ex: CIMT-constraint induced movement therapy
Constraint-Induced Movement
Therapy (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 Changes
• Cortical changes associated CIMT plus
pre post
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.
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 Electrical stimulation

•IG STIMULATION-
MOTOR RECRUITMENT

•RUSSIAN STIMULATION- MUSCLE

STRENGTHENING AND MUSCLE RE-EDUCATION
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 tone
through reciprocal inhibition.
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. 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
Motor Control
Facilitation techniques:
Kabat’s 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!
Individual psychotherapy- COUNSELLING.
Positive reinforcement of the progress in rehab.
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
•Allof the above five principles have to be translated
into FUNCTIONAL TASK & CONTEXT-ORIENTED
exercises!
REHAB Therapy for Early Phase
•Startas 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 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 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.
Management-
Gait 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!!!