1. Neuromuscular Rehabilitation By. Dr. H. El Sharkawy

3. After the Stroke, After the traumatic brain injury, After the spinal cord injury, After the medications were given or the appropriate surgical procedures were done, WHAT DO WE DO NEXT???

4. Neurorehabilitation 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.”

5. 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

6. 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.

7. Stroke and Hemiplegia Stroke is the third leading cause of death in the US and the leading cause of disability ◦ approx. 700,000 strokes; 160,000 deaths Modifiable risk factors include TIA, diabetes, hypertension, atrial fibrillation, substance abuse, and smoking Nonmodifiable risk factors include age, gender, race, and family history

8. Stroke and Hemiplegia Of those who survive the initial onset, the most frequent presenting problem is hemiplegia (75- 88%) During the acute period, there is high incidence of associated neurological deficits One important medical concern is the incidence of comorbidities that may affect management and rehab

9. Types Types 1. Ischemic (83%) ◦ Can be “silent ischemia” (no sx) ◦ Caused by atherosclerosis 2. Cerebral thrombosis (most common) ◦ blood clot forms in arteries leading from heart to brain (carotid) ◦ blocks blood flow ◦ Often preceded by TIA 3. Cerebral embolism ◦ less frequent ◦ blood clot forms elsewhere (embolus), travels through bloodstream, lodges in cerebral artery

10. Types 1. Hemorrhagic stroke ◦ less common than ischemic strokes ◦ more deadly ◦ if person survives, better recovery of function Why? ◦ Ischemic: Blood supply to brain stopped; tissues die, do not regenerate ◦ Hemorrhagic: pressure from blood compresses brain, affects function, pressure relieved, function returns

11. Hemorrhage subarachnoid hemorrhage ◦ blood vessel on surface of brain leaks ◦ bleeding into space between brain & skull cerebral hemorrhage (10%) ◦ Defective artery in brain bursts Causes: ◦ aneurysm (blood-filled pouches that balloon out from weak spot in artery) ◦ advancing age, congenital malformation ◦ aggravated by hypertension ◦ head injury

12. Stroke and Hemiplegia Right-Hemisphere Stroke ◦ The right hemisphere controls the movement of the left side of the body as well as analytical and perceptual tasks Left-Hemisphere Stroke ◦ The left hemisphere controls the movement of the right side of the body as well as speech and language abilities

13. Stroke and Hemiplegia Cerebellar Stroke ◦ The cerebellum controls many of our reflexes and much of our balance and coordination Brain Stem Stroke ◦ The brain stem is the area of the brain that controls all of our involuntary, “life-support” functions as well as abilities such as eye movements, hearing, speech, and swallowing

14. Symptoms sudden numbness, weakness face, arm, leg (one side of body) sudden severe headache difficulty seeing in one or both eyes confusion, trouble speaking or understanding dizziness, loss of balance/coordination

15. Treatment of a stroke Getting medical help quickly essential! Ischemic stroke: ◦ "Clot-busters" ◦ tissue plasminogen activator (tPA) ◦ Must give within 3 hours Hemorrhagic stroke: correct cause of hemorrhage

16. Some residual effects of strokes Emotional lability (mood swings, depression) Perceptual effects: Difficulty recognizing, understanding familiar objects Difficulty planning, carrying out simple tasks Loss of awareness (One-side neglect ) Dysphagia (difficulty swallowing) Aphasia: difficulty putting thoughts into words or understanding speech

17. Reactions & Rehabilitation social isolation grieving process(depression ). physical, occupational, speech therapy 20% require long-term care Recovery affected by extent of brain damage, patient’s attitude, support system, rehab. team skill

18. Voc Rehab and Stroke Estimated that 30% of strokes occur in people under 65 One study found a 49% RTW rate for people 21-65 year old Physical factors and aphasia play significant roles and complications in vocational planning

19. 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

20. 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!

21. 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

22. angiogenesis Axonal sprouting (neurogenesis) Unmasking of latent synapses (synaptogenesis) Regeneration from neural stem cells in the subventricular regions migrating to the periinfarct area. Mechanism of Neuroplasticity

23. Management- CIMT Liepert, et al. 2003. “demonstrated through transcranial magnetic stimulation mapping, that constraint-induced rehabilitation augmented the motor cortical areas representing hand movement for as long as 6 months”

24. 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

25. 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.

26. 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

27. Mirror Therapy

28. 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.

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

30. Management- FES Functional Electrical stimulation: The most promising technique for hemiparetic arm! Neuroprostheses

31. Management- FES Functional Electrical stimulation

32. Dynamic Finger Extension Splint

33. Management- FES Functional Electrical stimulation

35. Environmental simulationEnvironmental simulation Verbal and non- verbal stimulationVerbal and non- verbal stimulation Management

36. 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.

37. 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

38. 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.

39. Exercise Therapy to Develop Motor Control Facilitation techniques: Kabat’s Proprioceptive Neuromuscular Facilitation (PNF)

40. Exercise Therapy to Develop Motor Control Conventional methods: Stretching & strengthening Attempting to retrain weak muscles through reeducation

41. Hydrotherapy

42. Other Treatment for the Hemiparetic Arm EMG biofeedback

43. Management Wii Fit

44. 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

45. 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)

46. 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.

47. Management- Gait Training

49. Management- Therapeutic Exercises Tai-Chi exercises? - Slow movements emphasizing trunk and limb control Acupuncture? - variable results

50. Management- Balance Training

51. Management- coordination Training Bully Therapy

52. 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

53. Repetitive Transcranial Magnetic Stimulation

54. Important Points “Improved function may occur with vigorous and intensive therapy, strong motivation and good cognition; provided some selective hand movement is present”!* * Adams & Victor’s Principles of Neurology

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

56. Important Points “Neuroplasticity occurs better in motivated & moving patients”.

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

59. Purposeful activity Early and immediate intervention Appropriate intensity Management

60. Thank you