Stroke Rehabilitation

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Stroke Rehabilitation

• Wael Alasaq PT, PhD.
• Kuwait University
• Physical Therapy Dep.

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• Theory
• The importance of theories
• Motor control
• Motor learning

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Bases for rehabilitation

• What is a theory?
• An abstract idea that provide an answer or a
  description about a phenomenon.
• Motor control theories are abstract ideas about
  the nature and cause of movement.

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• Why do we use theories? What is the importance
  theories?

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What is motor control theory?

• Motor control is the study of the nature and
  cause of movement.
• Theory of motor control is a group of abstract
  ideas about the nature and cause of movement.
  Theories are often, but not always, based on
  models of brain function.

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Why there are many theories?

• For explaining
• Answering what is messing from others
• New discoveries

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How theories affect rehabilitation?

• In the past
• CNS is thought of as rigid and unalterable.
• Regeneration reorganization was not possible
  within the CNS.
• Treatment focus was on the use of what ever
  movement available (leading to compensation)

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How theories affect rehabilitation?

• Currently
• More recent research in the field of neuroscience
  show that adult CNS has great plasticity and an
  incredible capacity of reorganization.
• Thus ttt focus is on recovery ( achieving task
  goals using effective efficient means, but not
  necessarily those used premorbidly)

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Theories of motor control motor learning

• Reflex theory
• Hierarchical theory
• Motor programming Theory
• Systems theory
• Dynamical action theory
• Parallel distributed processing theory
• Task-Oriented theory
• Ecological theory

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Motor learning

• Motor learning the study of the acquisition
  modification of movement.

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Motor learning theories

• Adams Closed-Loop theory
• Schmidts Schema theory
• Fitts Posner Stages of motor learning
• Newells theory of learning as exploration

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Brain reorganization Functional recovery

• To date there is no medical intervention to
  reduce the extent of neural damage following
  stroke.
• How can we then improve functional outcome?

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Brain reorganization Functional recovery
Cont.

• Neural system is being remodeled throughout life
  after injury by experience in response to
  activity and behavior
  (Jenkins et al. 1990, Johansson 2000, Nudo et al.
  2001)

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Brain reorganization Functional recovery
Cont.

• Hebb (over half a century ago) suggested that
  neural cortical connections can be remodeled by
  our experience.

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Brain reorganization Functional recovery
Cont.

• Foundation for functional plasticity
• There is an extensive overlapping of muscle
  representation within the motor map, with
  individual muscle joint representations
  re-represented within the motor map
• Individual corticospinal neurons diverging to
  multiple motoneuron pools.
• Horizontal fibers interconnecting distributed
  representations. (Nudo
  et al. 2001)

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Brain reorganization Functional recovery
Cont.

• Changes in the nervous system may occur according
  to the patterns of use.
  (Pascual-Leone Torrres
  1993)
• These studies stress the changes associated with
  active, repetitive training practice, by the
  continued practice of the activity.
• Restriction of activity or disuse associated with
  immobilization or amputation causes alterations
  in the cortical representation (reduction).
  (Leipert et el. 1995)

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Brain reorganization Functional recovery
Cont.

• This suggests that the neural system is flexible
  and adaptive, and respond to many factors,
  including patterns of use.

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Brain reorganization Functional recovery
Cont.

• The current technology of imaging systems have
  confirmed that
• the cerebral cortex is functionally and
  structurally dynamic
• neural reorganization occurs in human cortex
  after stroke
• Altered neural activity patterns and molecular
  events influence this functional reorganization
  (Johansson 2000)

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Brain reorganization Functional recovery
Cont.

• Two types of processes underlying functional
  recovery following stroke
• Reorganization of affected motor regions
• Changes in membrane excitability
• Growth of new connections or unmaking of
  pre-existing connections
• Removal of inhibition and activity-dependent
  synaptic changes
• Plastic changes in subcortical regions.
• 2. Changes in the unaffected hemisphere.

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Brain reorganization Functional recovery
Cont.

• Importance of active use of the limb for the
  survival of the undamaged neuron adjacent to
  those damaged by cortical injury that retention
  of the spared hand area recovery of function
  after cortical injury might depend upon
  repetitive training and skilled use of the hand.

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Brain reorganization Functional recovery
Cont.

• There is relationship between PT intervention and
  reorganization of the cerebral cortex.
  Lieper et al. (2000)
• Usually the recovery of function starts 3-4
  weeks. During these 3-4 Wks there is resolution
  of edema, absorption of necrotic tissue debris
  and the opening of collateral channels for
  circulation to the lesioned area.

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The Rehabilitation Environment

• The reorganization functional recovery from
  brain lesion are dependent on 3 factors
• Use
• Activity
• Environment in which the rehabilitation is
  curried out.

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The Rehabilitation Environment cont.

• The rehabilitation environment is made up of
• The physical built environment (physical setting)
• The method used to deliver rehabilitation
• The staff, their knowledge, skills attitudes.

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Time spent on Activity
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Structuring a Practice Environment

• The goals of PT intervention are to provide
• Opportunities for an individual to regain optimal
  skilled performance of functional actions
• to increase level of strengths
• to increase level of endurance
• to increase level of physical fitness
• Emphasis should be placed on the time spent on
  practice as well as the type of practice
• (Small Solodkin 1998)

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Delivery of Physiotherapy

• Independent practice
• Group practice

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Group exercise training

• What kind of benefits it has on therapist,
  patient and training program?
• What are the factors that may influence the
  amount of independence practice?
• Patient's level of disability
• Willingness by the pt
• Understandability of the exercise to be curried
  out

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Group exercise training Cont.

• How to encourage understandability?
• Brief explanation with demonstration
• List of diagrams
• Workbook
• Feedback (verbal, graphs, number, speed etc)
• Personalized according to pt's needs situation

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Group exercise training Cont.

• Why do we need to increase time spent in
  exercise?
• Improve physiological responses, such as
  endurance, strength, and fitness.
• Improve functional motor performance (more
  repetitions leading to mastering the skill)
• Achieve goals of the treatment

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Optimizing skill

• What is a skill?
• A skill is
• 1- "Any activity that has become better organized
  more effective as a result of practice
  (Annett 1971)
• 2- "The ability to consistently attain a goal
  with some economy of effort
• (Gentile 1987)

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Optimizing skill Cont.

• How to optimize a skill?
• Braking the movement down into its segmental
  constituents
• Task oriented training to gain the necessary
  control
• Through training and repetition muscle motor
  learning is taking place and more strength is
  gained.

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Optimizing skill Cont.

• Stages of learning skills
• Cognitive stage ( getting the idea of the
  movement)
• Intermediate or associative stage (preparing for
  adaptation of the movement pattern)
• Final or autonomous stage (owning it, mastering
  it)

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Optimizing a skill Cont.

• Factors for optimizing a skill
• a- focusing attention
• b- Provision of feedback
• c- Transfer of learning
• d- Practice

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A- Focusing attention

• Learning of motor skills involves
• Identifying what is to be learned.
• Understanding the ways for goal accomplish

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Identifying what is to be learned

• Two methods for directing the focus of attention
• Demonstration (live recorded) (Fig 1.4)
• Verbal instruction
• Should be brief
• Simple (no too much details, U will kill him)
• In a language that is understood by the patient
  (Fig 1.5)

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Understanding the ways for goal accomplish

• Setting goals, should be
• Meaningful
• Reasonably challenging but yet attainable

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b- Feedback

• Very important for skill acquisition about
  performance.
• There are two types of feedback, intrinsic and
  extrinsic (augmented)
• Intrinsic, is the sensory feedback (visual,
  proprioceptive, tactile)
• Extrinsic (Augmented) feedback provide knowledge
  of the result of action (KR) and knowledge of the
  performance (KP), such as therapist or instrument
  (e.g. EMG)

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C- Transfer of learning

• Transfer training (learning) from practice
  environment (rehabilitation setting) to other
  environments.
• A closed motor skill vs. Open motor skill

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d- Practice

• Optimizing performance through repetition in
  order to increase strength, skill development as
  well as training for muscle coordination.

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d- Practice Cont.

• Discuss how would you keep patients
• motivated during practice, as it involves
• repetition of actions?

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d- Practice Cont.

• Remember
• Patients need to practice in different
• contexts in order to develop flexibility to
• apply motor tasks into different
• environment..