Rehabilitation for

Neuromuscular conditions
Husnul Mubarak, Sp.KFR
 Introduction
• Neurorehabilitation is the clinical branch of
medicine devoted to the restoration and
maximization of functions that have been
lost due to impairments caused by injury
or disease of the nervous system
 Principle of neurorehabilitation
• Neuroplasticity ability of neurons to adjust their
activity and even their morphology to alterations
in their environment or patterns of use.
• Nerve regeneration, the ability of damaged
neuron to exhibit physiological growth in distal
ending, finally reaching the dennervated tissues
• Neural repair, the range of interventions by
which neuronal circuits lost to injury or disease
can be restored
 Principle of rehabilitation
intervention
• Sending impulse to the higher level of
neurons  stimulates neuroplasticity in
brain/promoting neural regeneration in
peripheral nerve
– EXERCISE
– Physical modalities
Diseases – Illness – Conditions
• Central nervous system
– CVA / Stroke
– Neoplasm – Space occupying
lesion
– Mechanical Trauma
– Autoimmune
– Infections
– etc
• Peripheral nervous system
– Radiculopaty : cervical and lumbal
• Cervicalgia and Low back pain
• Cervical root syndrome and lumbar radiculopathy
– Entrapment neuropathy : TOS, Saturday night palsy,
canal of guyons neuropathy, carpal tunnel syndrome,
– Metabolic neuropathy : Diabetic neuropathy
– Infections : Herpetic Trigerminal
– Mechanical trauma
– Autoimmune : GBS, Acute Inflammatory
Demyelinating Polyradiculoneuropathy
– Idiopathic : Bell’s palsy
 Location of neural lesion
• Telencephalon
• Diencephalon
• Mesencephalon
• Cerebellar
• Brainstem : Pons and Medulla oblongata
• Spinal Cord : Ascending tracts – Descending tracts
• Radix : Cranial nerves - Spinal nerves
• Autonomic ganglia : Simphatetic/Parasimpathetic ganglia
• Peripheral : Demyelinating, axonopathy, axonotmesis
• Neuromuscular junctions
 Common direct impairment of
nerve insult
• Consciousness disruption
• Cognitive loss
• Headache, Vertigo, Lightheadedness
• Language problem and orofacial disorder
• Muscle weakness
• Spasticity
• Abnormal sensation
• Autonomic disorder
• Involuntary movement
 Common disability
• Transfer disorder  Prolong
immobilization  Deconditioning
• Postural imbalance : Sitting and Standing
• Ambulation disorder
• Hand function skill limitation
• Toileting problems
• Self care independency
 Common handicap
• Geographic/Architectural Limitations
• Disruption of Social participation
• Unemployment
• Loss of Self actualization
STROKE :
THIS IS NOT JUST A DISEASE,
THIS IS A DISASTER !
FUNCTIONAL PROGNOSIS OF STROKE :

1. 75% of patients will reach independent level of

self-care or with minimal help and independent
level of ambulation w/ assistive device
2. Almost all patients will be able to control
bladder and bowel
3. Only 10-15% of patients fall into severe
disabilities and will be bedriddened
 The first step of Rehabilitation
Medicine Program :
1. TO ESTABLISH THE DIAGNOSIS OF STROKE
Haemorrhagic / Non-Haemorrhagic ?

2. TO IDENTIFY IMPAIRMENTS, DISABILITIES, AND POSSIBLE HANDICAP

WHY Those IMPORTANT ?
1. To anticipate the possible
problems which will be developing
2. Set up possible goals
3. To decide the appropriate
rehabilitation medicine strategy
 GOALS OF REHABILITATION MEDICINE
PROGRAM
1. Preventing complications
2. Teaching new adaptive methods
3. Ensuring that appropriate aids are provided
and used properly
4. Retraining the damaged nervous system and
preventing or overcoming “learned disuse”
5. Enhancing Quality of Life
PHYSICAL THERAPY
 Basic Physical Therapy
• Bed positioning, mobility  Antispasticity position,
gradual mobilizaton
• Range of motion exercises (ROM)
• Motoric reeducation : PNF concept, Bobath,
Brunstorm, Rood, Carr & Shepherd, ect
• Spasticity inhibition
• Sitting/standing balance control training
• Ambulation  Gait rehabilitation
• Stair climbing
• Use of physical modalities  mostly for
musculoskeletal consequences & pain
STEPS OF AMBULATION TRAINING
OCCUPATIONAL
THERAPY
 Occupational Therapy
• Focuses on fine motor development
• Developing new adaptive
technique/devices
• Improving independency of ADL
• Training of vocational skills
• Energy expenditures
• Mirror therapy
• Sensory reeducation
 Mother
language

SPEECH THERAPY
 Speech therapy
• Training of orofacial motor and stimulation
• Concept of language and vocabularies
• Training of phonation and articulation
• Chewing, feeding, and swallowing training
AMBULATION TRAINING
&
GAIT EXERCISES

START LOW, GO SLOW

WALKERS
Orthotic
 Orthotic
• Shoulder  Preventing shoulder
subluxation  Shoulder sling/Axillary roll
• Wrist  Extensors spasticity w/
Functioning fingers  Cock up splint
• Legs  Flexion spasticity 
HKAFO/KAFO
 OTHER APPROACHES
• CIMT (Constraint-Induced Movement
Therapy)
• FES (Functional Electrical Stimulation)
• EMG-BIOFEEDBACK
• ROBOTIC DEVICES
 GOOD
PROGNOSIS

APPROPPRIATE,
COMPREHENSIVE,
MOTIVATION
WELL-PLANNED
PROGRAM
Low back pain
Definition
• symptoms of pain in the low back area
• 80% people have ever felt it once in their lifetime
• Consequences of change from quadripedal
toward bipedal  COG located 1 inch anterior
from corpus S2  Trunk extensors work harder
• Multietiologi  muscular, discal,
ligamentum, facet, radicular, medulla
spinalis and or combinations
• 2 factors : - Mechanicals 95
- Organic 5%
• 1st Identify, is it musculogenic or
neurogenic or combinations
Prone individuals
Beware of Red Flags
 Diagnosa Anamnesa Pemeriksaan Penunjang Terapi
Fisik

LBP Postural - Muncul X ray lumbosacral - Medikasi

mendadak yang - Tender point AP/Lateral - Modalitas
dipengaruhi oleh - Spasme m. - Proper back
posisi tubuh paralumbal mechanism
- Nyeri tidak - Latihan
menjalar
- Kesemutan –
- Rasa tebal –

LBP ec - Primer - Tender Point X-ray - Medikasi

Spondylosis degeneratif - Spasme m. Lumbosacral - Modalitas
Lumbalis pada disk Paralumbal AP/Latera/ - LS Korset
intervertebral+ - Merambat ke : Osteofit - Proper Back
Corpus sacrogluteal region Mechanism
vertebra - Latihan
- Morning
Stiffness
- Nyeri konstan
- Limitasi ROM
- Limitasi durasi
berdiri/duduk
Diagnosa Anamnesa Pemeriksaan Fisik Pemeriksaan Terapi
tambahan
LBP ec - Nyeri punggung yang - Gait - EMG-NCV: - Medikamentosa
HNP/ menjalar hingga ujung - Pemeriksaan Peningkat - Diatermi
Radiculopati jari kaki kekuatan otot an potensial - TENS
- nyeri muncul mendadak sesuai myotom insertional, - ES
setelah membungkuk - Pemeriksaan Prolonge - Exercise
atau mengangkat benda sensoris sesuai durasi - Ortesa
berat dermatom potensial - Pembedahan
- Berupa nyeri tajam, - Pemeriksaan motor unit,
tumpul, seperti terbakar khusus : SLR, partial
atau berdenyut2 Bragard, Siccard interferensial
- Nyeri bertambah jika - Refleks fisiologis potensial
membungkuk ke depan dan patologis sepanjang
atau samping, duduk, - Status lokalis : kontraksi
batuk. knock pain, tender voluntar
- Nyeri berkurang dengan point maksimal
berbaring, berjalan. - Pemeriksaan bowel - X- Ray :
- Kelemahan otot berdasar & bladder Normal disc
myotom space
- Defisit sensoris berdasar - MRI
dermatom
- gangguan bowel &
bladder (cauda equina
syndrome)
 Low Back Pain
Diagnosa Anamnesa Pemeriksaan Penunjang Terapi
Fisik
Fraktur Kompresi -Riwayat trauma -Nyeri tekan dan -X ray dan MRI: -Medikasi
-Nyeri terlokalisir nyeri ketok pada tampak adanya -Modalitas
pada level fraktur lokasi fraktur fraktur/kompresi -Orthosis
-Deformitas area pada tulang -Bedah
vertebra vertebra
-Defisit neurologis -Gambaran
osteoporosis (
bila ada)

Spondilitis TB -Riwayat -Gibus -X ray dan MRI: -OAT

menderita TBC -Pembengkakan tampak adanya -Modalitas
-Riwayat kontak di sekitar lipatan proses pengejuan -Orthosis
-Gejala TBC paha (abses) pada tulang - Bedah
(demam, -Spasme otot di vertebra (corpus) (debridemant &
penurunan berat area yang -Tuberkulin test + stabilisasi)
badan) terinfeksi -Aspirasi pus
-Nyeri berkurang -Defisit neurologis paravertebral
dengan istirahat
 Diagnosis Anamnesa Pemeriksaan Penunjang Terapi
Fisik
Ankylosing -Nyeri dan -Limitasi ROM -X-ray: -Medikasi
Spondylitis Kekakuan leher, spine bambooing -Flexibility
trunk, dan hip -Schobber test + spine, sacroilitis exercise
yang progresif -Tanda sacroilitis -Lab: LED, HLA- -strenghtening
-Pada fase akhir, -Penurunan B27 exercise
nyeri berkurang, chest expansion -Chest expansion
kaku bertambah exercise
-Morning -ADL
stiffness modification
-Bedah
LBP ec - Usia > 50th -Tenderness -X-ray -Medikasi
malignancy -Nyeri tumpul yang terlokalisir lumbosacral -TENS
-Throbbing -Bisa timbul -MRI, CT Scan -isotonic
-Slowly defisit neurologis -Bone scanning strengthening
progressive -Sering ada -Biopsi exercise
-Nyeri meningkat demam -orthosis
ketika berbaring -Penurunan berat
dan batuk badan dan
kondisi umum
 Principle of LBP management
• Finds out the source
• Pain management  pharmacological, physical modality
(electroteraphy, Laser, and thermal therapy)
• Spasm treatment  diathermy – trunk stretching
exercise – traction
• Maintenance trunk strength  Strengthening exc for
core muscle & Endurance exc for trunk muscles
• Supportive orthoses  depends on diagnosis
• Myotomal weakness  Strengthening exc of lower
extremities
• Dermatomal sensory loss  Reeducation
• Home Education and Exercise program
Proper back mechanics
Posisi duduk ke Berdiri yang
salah
Posisi dari duduk ke berdiri yang benar
 Back Exercise
The goals of performing these exercises were
• to reduce pain and

• provide lower trunk stability by

- actively developing the "abdominal, gluteus

maximus, and hamstring muscles as well as..."

- passively stretching the hip flexors and lower

back (sacrospinalis) muscles.

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 Williams' Flexion Exercises
1. Pelvic tilt.
Lie on your back with knees
bent, feet flat on floor. Flatten
the small of your back against
the floor, without pushing
down with the legs. Hold for 5
to 10 seconds.

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2. Single Knee to chest.

Lie on your back with knees

bent and feet flat on the
floor. Slowly pull your right
knee toward your shoulder
and hold 5 to 10
seconds. Lower the knee
and repeat with the other
knee.

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3. Double knee to chest.

Begin as in the previous

exercise. After pulling right knee

to chest, pull left knee to chest

and hold both knees for 5 to 10

seconds. Slowly lower one leg at

a time.

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4. Partial sit-up.

Do the pelvic tilt (exercise

1) and, while holding this
position, slowly curl your
head and shoulders off the
floor. Hold briefly. Return
slowly to the starting
position.

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5. Hamstring stretch.

Start in long sitting with toes

directed toward the ceiling
and knees fully
extended. Slowly lower the
trunk forward over the legs,
keeping knees extended,
arms outstretched over the
legs, and eyes focus ahead.

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6. Hip Flexor stretch.

Place one foot in front of the

other with the left (front) knee
flexed and the right (back) knee
held rigidly straight. Flex
forward through the trunk until
the left knee contacts the
axillary fold (arm pit
region). Repeat with right leg
forward and left leg back.

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7. Squat.

Stand with both feet parallel,

about shoulder’s width
apart. Attempting to maintain the
trunk as perpendicular as possible
to the floor, eyes focused ahead,
and feet flat on the floor, the
subject slowly lowers his body by
flexing his knees.

www.backtrainer.com
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 Typical McKenzie Back Extension
Exercises

1. Prone lying. Lie on your stomach with

arms along your sides and head turned to
one side. Maintain this position for 5 to 10
minutes.
2. Prone lying on elbows. Lie on your
stomach with your weight on your elbows
and forearms and your hips touching the
floor or mat. Relax your lower
back. Remain in this position 5 to 10
minutes. If this causes pain, repeat
exercise 1, then try again.
3. Prone press-ups. Lie on your stomach
with palms near your shoulders, as if to do
a standard push-up. Slowly push your
shoulders up, keeping your hips on the
surface and letting your back and stomach
sag. Slowly lower your shoulders. Repeat
10 times.
4. Progressive extension with
pillows. Lie on your stomach and place a
pillow under your chest. After several
minutes, add a second pillow. If this does
not hurt, add a third pillow after a few more
minutes. Stay in this position up to 10
minutes. Remove pillows one at a time
over several minutes.
5. Standing
extension. While
standing, place your
hands in the small of
your back and lean
backward. Hold for
20 seconds and
repeat. Use this
exercise after normal
activities during
the day that place
your back in a flexed
position: lifting,
forward bending,
sitting, etc.
 General Instruction
1. Do all exercises on the floor or a hard
surface.
2. Do each exercise twice a day, 5 times each,
increasing the number as strength increases.
3. Do not rush, always allow adequate time.
4. Do not hold your breath
5. Consult your therapist/doctor if an exercise
increases pain.
Therapeutic exercise, 3rd edition, John V. Basmajian

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Thank you