OCC 3003 Week 3 Stroke Motor Rehabilitation (Revised 13-9-24) PDF

Ray Li Senior Clinical Associate School of Medical and Health Sciences Email : [email protected] Tel : 3468 6740 office : MKB2201a OCC 3003 Enabling Occupation Health care III Week 3 Lecture Stroke motor impairment and rehabilitation 2 Lectureoutline: Stroke brief introduction Motor impairment Neuroplasticity Different approaches Rehabilitation of Upper Limb Stroke : motor impairment and rehabilitation 3 Stroke (CVA) care is a major healthcare issue in Hong Kong. In 2022, it was the fifth Cerebral leading cause of death and first leading cause of disability. vascular The age-specific mortality rate was 4230 per 100,000 population among patients age 65 Accident Around 25,000 admission per year in HK with 3164 died in 2022 a crude death rate of 42.3 CVA per 100 000 population. 4 statistics Stroke Statistics 2020 ‧On average, someone dies from a stroke every six seconds around the world. ‧Mortality rate in the first year after stroke is 20-25% · No.4 cause of death in Hong Kong ‧Stroke kills about 3000 people a year in Hong Kong Death number by Leading Causes of Death 2020 1 Malignant neoplasms 14800 2 Pneumonia 9365 3 Diseases of heart 6561 4 Cerebrovascular diseases 3165 5 Immediate treatment: ‧ tPA ‧ operation 導管吸⾛ leision ischemic case: blood flow to leision in brain -> increase leision size 談笑⽤兵 (usually for ischemic) 談：slur of speech/drooping when to do open skull operation: 笑：asymetry of smile 1. see if pupil 放⼤⽤：numbness + weakness 2. see whether midbrain no more 功能兵：⿈⾦3-4⼩時 CVA 3. hematoma > 2cm Neuro test for weakness: 1. hold up two hands (lower one weaker) 2. finger nose test 3. heel shin test happens in younger generation DM causing blood vessel brittle (~海浪撞⽯) -> high BP aneurysm ⾎管瘤 happens in elderly 8 Central Nervous system CT brain can scan internal capsule and thalamus infarct The CNS is formed by the upper motor neurons internal capsule (UMN) which carry signals for movement down to basal ganglia the lower motor neurons (LMN) – -> gait control signal the muscles to either contract or relax An upper motor neuron (UMN) lesion is a lesion of the neural pathway above the anterior horn of the spinal cordor motor nuclei of the cranial nerves. CNIII, IV, VI -> control eye movement UMNs synapse directly on LMNs or influence cross at medulla oblongata them indirectly via interneurons microphone: 咪套 = basal ganglia thalamus lateral corticospinal tract : anterior corticaospinal tract 9:1 brain stem active movement : unconcious control (e.g. trunk) medulla oblongata 9 Spinal cord injury less aﬀect if lower if upper -> spasm + paralysis 1. no unconciousness + eye contact 2. can follow and understand > 3 verbal command e.g. 攞起⼿ -> ﬀan放上頭 3. check wheher aﬀected side movment have minimal active movement (if have = cortical spinal tract have connection) constrained reduced therapy -> make sure CST have connection muscle tone: 2-3 diﬃcult 3-4 more diﬃcult Motor control system Babinski sign (assess CST) +ve sign: big toe extent ACA support LL -ve sign: big toe flexion 1. Cerebral cortex foot Primary motor area forming corticospinal (pyramidal) pathways Premotor & supplementary motor cortices for programming Prefrontal cortex planning and initiation of willed activity Parietal cortical areas emotion important for guidance of movement Association areas acting through conscious or unconscious information also guide motor system 2. Subcortical centers basal ganglia (striatum, pallidum, substantial nigra, subthalamic nucleus) cerebellum maintenance of tone, posture, and co-ordination of movement Brainstem Spinal cord 10 Pyramidal tracts originate in the cerebral cortex to the spinal cord and brain stem Motor voluntary control pathways – Lesions → spasticity descending Extrapyramidal tracts originate in the brain stem tracts to the spinal cord involuntary and automatic control control of body posture Lesions → rigidity 11 Spinal Nerve and motor control Enhance the ability of motor control system for coordinated motor activity Receptor --> sensory fiber --> interneuron --> alpha motor neuron --> muscle Cutaneous reflex – like withdrawal reflex Muscle reflex – stretch reflex 12 Motor control system Brainstem – relay station – through its nuclei specially pons and medullary (reticular nuclei, vestibular, and red nuclei) – on muscle stretch reflexes, posture, reflex, and repetitive movements Spinal cord – motor execution – neuronal circuits and motor subsystems Motor unit – consisting of a motor neuron and all the muscles it innervates Spinal cord reflexes – enhance the ability of motor control system for coordinated motor activity 13 Circulation of brain vestibular 14 M4 15 Circulation of brain Anterior and middle artery ba sa lg an lia + in tern al ca ps ule Posterior artery 16 17 18 Middle cerebral artery is very common involved while anterior cerebral artery is less. MCA covers over 2/3 of the medial surface of the MCA hemisphere including frontal and parietal lobe. It covers the primary motor and sensory area of the contralateral extremity which responsible for all voluntary movement and sensory feedback of limbs and body. 19 MCA 20 21 Ischemic stroke In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are reasons why this might happen: no move e.g. cholestrol Thrombosis (obstruction of a blood vessel by a blood clot forming locally) move e.g. aneurysm -> may precribe 薄⾎丸 70% Embolism (obstruction due to an embolus ( moving clots)from elsewhere in the body.) Systemic hypo perfusion (general decrease in blood supply to the brain , e.g. in shock, poisoning ) 22 Thrombosis 23 Hemorrhagic stroke hemorrhage: brain cell can still recieve blood -> better performance in rehab ischemic: brain cell dead cuz no blood -> may not retain functions Cerebral hemorrhage ICH (also known as intracerebral hemorrhage), which is basically bleeding within the brain itself, due to either parenchymal (bleeding within the brain tissue) or intra ventricular (bleeding within the brain's ventricular system ). cranial operation take away part of the skull -> put back after half year Treatment depends substantially on the type of ICH. Rapid CT scan and other diagnostic measures are used to determine proper treatment, which may include both medication and surgery. 24 Hemorrhagic stroke Subarachnoid hemorrhage,(SAH) which is basically bleeding that occurs outside of the brain tissue but still within the skull. Between the meninges and brain tissue. Treatment is by prompt neurosurgery. 25 Lacunar stroke when thalamus aﬀected -> thalamus pain = messy sensation happens in white matter Lacunar stroke also called subcortical stroke or lacunar infarct, often arise from chronic high blood pressure, which leads to progressive narrowing and finally blockage of the small thread-like arteries within cerebral tissue of the brain. Lacunar stroke syndrome could be due to either ischemia or a small hemorrhage. Lacunar ischemic stroke is defined as a stroke that is attributable to a recent small infarct if yes, do not do 2. mental stage 3. BP flutuate? 29 Time Course of Recovery Peak neurological recovery from stroke occurs within the first one to three months. depends on size and severity of aﬀected area A number of studies have shown that recovery may continue at a slower pace for at least 6 months; with up to 5% of patients continuing to recover for up to one-year. MBI grade lower than normal This is especially true with patients who are severely disabled at the time of initial examination. (Bonita & Beaglehole 1988, Duncan et al. 1992, Ferrucci et al. 1993, KellyHayes et al. 1989, Wade et al. 1983, Wade et al. 1987). 30 Time Course of Recovery The return of motor power is not synonymous with recovery of function. young stroke recovery more 明顯 Function may be hampered by the inability to perform skilled coordinated movements, apraxia, sensory deficits, communication disorders as well as cognitive impairment. Functional improvements may occur in the absence of neurological recovery 31 Predictors of Stroke Recovery Hemorrhagic versus Ischemic Stroke Hemorrhagic strokes have been associated with more severe neurological deficits and are generally thought to have a higher mortality rate. initial state ischemic looks better than hemorrage, but in recovery, hemorrage has greater recovery from ischemic The apparent poorer outcome among patients with hemorrhagic stroke was attributed to greater initial stroke severity compared to patients with ischemic stroke than ischemic strokes of similar severity. Hemorrhagic stroke patients with the most severely disabling strokes had significantly greater recovery than ischemic strokes of similar severity. The greater gains in hemorrhagic strokes to better neurological recovery associated with resolving brain compression 32 Mechanisms of Neurological Recovery Processes of Neurological Recovery 1. Post-Stroke edema 2. Reperfusion of the ischemic Penumbra 3. Diaschisis resolution 33 Post-Stroke Oedema 溶⾎劑有好有唔好 Oedema surrounding the lesion may disrupt nearby neuronal functioning. Some of the early recovery may be due to resolution of edema surrounding the area of the infarct (Lo 1986) and as the edema subsides, these neurons may regain function. This process may continue for up to 8 weeks but is generally completed much earlier (Inoue et al. 1980). Cerebral hemorrhages tend to be associated with more edema, which take longer to subside, but which may in turn be associated with a more dramatic recovery. 34 Reperfusion of the Ischemic Penumbra Reperfusion of the ischemic penumbra is another local process which can facilitate early recovery. A focal ischemic injury consists of a core of low blood flow which eventually infarcts (Astrup et al. 1981, Lyden & Zivin 2000), surrounded by a region of moderate blood flow, known as the ischemic penumbra (Astrup et al. 1981, Lyden & Zivin 2000), which is at risk of infarction but is still salvageable. Reperfusion of this area causes affected and previously nonfunctioning neurons to resume functioning with subsequent clinical improvement. 35 premotor frontal common MCA infarct area 36 Diaschisis resolution Diaschisis is a state of low reactivity or depressed function as a result of a sudden interruption of major input to a part of the brain remote from the site of brain damage. With injury to one area of the brain, other areas of brain tissue are suddenly deprived of a major source of stimulation. Nudo et al. (2001) noted that diaschisis occurs early after injury and is an inhibition or suppression of surrounding cortical tissue or of cortical regions at a distance that are interconnected with the injury core. The reversibility may be partially due to the resolution of edema, which may account for a portion of spontaneous recovery (Nudo et al. 2001). Neuronal function may return following the resolution of diaschisis, particularly if the connected area of the brain is left intact 37 Mechanisms of Neurological Recovery dendroid can recover CNS Reorganization (Later Recovery) Neurological reorganization plays an important role in the restoration of function. It can extend for a much longer period of time than local processes, such as the resolution of edema or reperfusion of the penumbra, and is of particular interest because it can be influenced by rehabilitation training. Nudo (2003), based on animal research, has suggested that changes occurring during motor learning ( synaptogenesis and increases in synaptic strength), are likely the same type of changes that occur during this part of recovery from stroke. This has been well shown after small, focal lesions in the motor cortex where the same principles of motor learning and development of functional connections are occurring in adjacent, undamaged tissue. ( neurogenesis) 38 Neuroplasticity Brain plasticity refers to the capacity of the nervous system to change its structure and its function over a lifetime, in reaction to environmental diversity Neuroplasticity, or neural plasticity, allows neurons to regenerate both anatomically as well as functionally, and to form new synaptic connections. Brain plasticity, or neuroplasticity, is the ability for the brain to recover and restructure itself. This adaptive potential of the nervous system allows the brain to recover after disorders or injuries and to reduce the effects of altered structures due to pathologies such as Multiple Sclerosis, Parkinson's disease, cognitive deterioration, Alzheimer’s, dyslexia, ADHD ,Insomnia, etc. brain cannot stop, keep activate stimulation 39 Synaptic plasticity rehersal -> enhance strong bonding -> network activate more smooth When engaged in new experiences and learning, the brain establishes a series of neural pathways. These neural pathways, or circuits, are routes made of inter-connecting neurons. These routes are created in the brain through daily use and practice; much like a mountain path is made by daily use of a shepherd and his herd. The neurons in a neural pathway communicate with each other through connections called synapses, and these communication pathways can regenerate throughout your whole life. Each time that we gain new knowledge (through repeated practice), the synaptic communication between neurons is strengthened. A better connection between the neurons means that the electric signals travel more efficiently when creating or using a new pathway 40 Neuron 41 Synapse a synapse is a structure that permits a neuron or (nerve cell) to pass an electrical or chemical signal to another neuron or to the target effector cell. stimulate + inhibit sympathetic（increase pulse = 陽） parasympathetic（relaxation = 陰） 42 Synaptic plasticity Neural networks before training Neural networks 2 weeks Neural networks 2 after stimulation months after stimulation 43 through stem cell may make brain cell re-alive Neurogenesis Whereas synaptic plasticity is achieved through enhancing communication at the synaptic site between existing neurons, Neurogenesis refers to the birth and proliferation of new neurons in the brain. Previously, Scientists believed that neurons died and were never substituted by new ones. Since 1944, but mostly in recent years, the existence of neurogenesis has become scientifically established and we know that it occurs when stem cells, a special type of cell located in the dentate gyrus, the hippocampus and possibly in the pre-frontal cortex, divide into two cells: a stem cell and a cell which will become a neuron fully equipped with axon and dendrites. Those new neurons will then migrate to distant areas of the brain where they are needed, and thus have the potential to allow the brain to replenish its supply of neurons. 44 hippocampus stem cell, neuron cell can regenerate and migrate back to neccessary area fragile -> easy to be affected by degeneration hormone control LTM gait control STM attention (10-15min) 45 Functional Compensatory Plasticity The neurobiological decline that accompanies aging is well documented in research literature and explains why older adults perform worse than young adults on tests of neurocognitive performance. Surprisingly, not all older adults exhibit lower performance, some do as well as their younger counterparts. This unexpected behavioral advantage for a sub-group of aging individuals has been scientifically investigated and it was found that, when processing new information, higher performing older adults recruit the same brain regions as do the younger adults, but, also recruit additional brain regions that young and low performing older adults do not activate. New learning induces new area of brain development. 46 Functional Compensatory Plasticity Researchers have pondered on this over-recruitment of brain regions in high performing older adults and have generally reached the conclusion that recruitment of additional cognitive resources reflects a compensatory strategy. In the presence of age-related deficits and decreased synaptic plasticity which accompany aging, the brain, once again manifests its multi-source plasticity by re-organizing its neurocognitive networks. Studies show that the brain reaches this functional solution through the activation of alternative neural pathways, which most often activate regions in both hemispheres (when only one is activated in the younger adults). 47 Conditions for inducing plasticity hand function most difficult to train (small msucle), LL can be trained most of the time (big muscle) proximal to distal training Intellectual and mental activity induce brain plasticity when applied to healthy older adults or to older adults with a neurodegenerative disorder. Cognitive training seems ideal for inducing cerebral plasticity. It provides the systematic practice necessary for establishing new neural circuits and for strengthening the synaptic connections among the neurons in the circuit. forgot things recently learned easily, things learnt earlier wont forgot easily However, as we have seen, in the absence of a tangible behavioral benefit, the brain will not learn effectively. Thus, the importance of integrating highly personalized and relevant goals with the training cannot be overstated. repeatative rehersal (at least 3 times) 1. scan 2. process and understand 3. recap (to LTM) e.g. learn grasp and release 望住learn to involve cognitive function, not only involve muscle memory 48 Motor Impairment and Neural Plasticity motor control detelorate more than sensory Motor learning results in changes in the motor cortex. Sensory stimulation may facilitate motor recovery. Intensive training increases brain plasticity. Enriched environments result in a greater number of synapses. The greater the damage to a specific brain area, the greater the plasticity in adjacent areas (Teasell & Hussein, 2013) Various stroke rehabilitation techniques have been developed based on the concept of neural plasticity. However, the effectiveness of interventions among patients with stroke varies widely because the mechanisms underlying motor recovery are diverse and, as yet, not well understood. 49 Motor problems of CVA Abnormal Tone Following a stroke, abnormal muscle tone is a common complication. Many of those who survive a stroke experience an abnormal increase in muscle tone referred to as spasticity or hypertonia. Additionally, many stroke patients experience an abnormal decrease in muscle tone, which is referred to as paresis or hypotonia. Both spasticity and paresis typically occur on one side of the body, usually the opposite side from the brain lesion. 50 e.g. clonus in leg extension -> put in ﬂexion (leg is extension dominate) -> compress on quadripcap tendon clonus in hand ﬂexion -> put in extension + pronation (hand is ﬂexion dominate) -> compress on palm There are a number of other abnormal signs associated with muscle over- activity: intension trama = 想move時係咁震, 唔move時唔震 vs Increased deep tendon reflexes (also called tendon jerks) 不⾃主咁震 dur to reﬂex, immodulate (more common in LL) Clonus—rapid, involuntary muscular contractions and relaxations Extensor and flexor spasms AFO (anti footdrop orthrosis) -> keep heel strike Babinski sign—an upward extension of the big toe when the sole of the foot is stroked or stimulated with a blunt instrument Positive support reaction—a reflex pattern of plantar flexion and inversion of the ankle during weight bearing Co-contraction—the simultaneous contraction of the agonist and antagonist muscles surrounding a particular joint Spastic dystonia—involuntary muscle contractions that cause slow repetitive movements or abnormal postures 51 Positive and negative signs UMN This type of muscle over-activity comprises the positive signs of upper motor neuron damage.* Decrease in muscle tone, visual loss, loss of dexterity, sensory loss, reduction of deep tendon reflexes, and numbness are referred to as negative signs of upper motor neuron damage (Trompetto et al., 2014). 52 Spasticity (Hypertonicity) Spasticity is defined as a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks, resulting from hyper- excitability of the stretch reflex. Spasticity is most often seen in the flexor muscles of the upper limb and in the extensor muscles of the lower limb.(Trompetto et al., 2014). Rehabilitation is a challenging task for those who exhibit spasticity. It can limit practice of coordinated movement, restrict movement, and hinder functional recovery. This abnormally elevated muscle tone impacts quality of life because it affects many aspects of everyday function, produces pain and discomfort, and prevents normal movements. Multiple medications and treatments have been developed and are used routinely in the clinical setting for post stroke spasticity, including baclofen, tizanidine, dantrolene, and benzodiazepines (Francisco & McGuire, 2012) 53 Hemiparesis and Hemiplegia Paresis or paralysis following a stroke is defined as “decreased voluntary motor unit recruitment, which reflects the inability or difficulty in recruiting skeletal motor units to generate torque or movement” (Shumway-Cook & Woollocott, 2012). It is the result of damage to the part of the nervous system and brain associated with motor control. Depending on the size and location of the lesion, weakness can range from complete loss of motor activity (paralysis) to partial loss (paresis). 54 Hemiparesis and Hemiplegia Weakness and loss of dexterity are usually immediately apparent following a stroke and often contribute to decreased active and passive range of motion of the involved joints. Profound hemiparesis can lead to joint contractures, which severely impair mobility and may lead to pressure ulcers. Passive and active range of motion exercises are used to reduce the risk of secondary musculoskeletal impairment from decreased joint range of motion (Trompetto et al., 2014). Paresis affects all activities of daily living. For example, a patient with hemiparesis bears more weight on the opposite lower extremity, which can lead to asymmetry and impaired posture. The weight- bearing asymmetry is associated with the increased postural sway and poor balance. The inability of the non-affected lower extremity to compensate for the paretic limb also contributes to the postural imbalance. 55 Synergy movement flexion synergy patterns, these synergistic movements result from multiple muscle contractions that are triggered at once. For example, if you try to move your shoulder, your elbow and wrist might contract as well. While flexor synergy can be a sign of recovery, this can also inhibit movements and daily activities such as reaching and self- care. Coordinated muscle movements are a result of different muscle groups working together. These movement patterns are called synergies, and are responsible for muscle contraction and motions that appear smooth and controlled. 56 Synergy movement To complete a successful movement, two things must happen at once: The agonist muscles (the muscles that initiate the movement) must contract. The antagonist muscles (the muscles that inhibit the movement) must relax. The brain is in charge of coordinating these movements, making sure the muscle groups do not accidentally conflict with each other. It does this by sending inhibitory or excitatory signals to the right muscle groups so they contract in a way that is synchronized and efficient. After a stroke, however, your brain’s ability to send the correct signals to the muscle groups may be inhibited. This creates difficulty activating single muscle groups, meaning multiple muscle groups may fire at once instead of individually. As a result, these synergies become mixed up and strange or frustrating patterns can occur 57 Flexor synergy pattern External rotation and abduction of the shoulder Flexion of the elbow Supination or pronation of the forearm Flexion of the wrist and fingers whenever you try to move your affected arm, your shoulder will raise, your elbow will bend, and your wrist may turn until your palm faces up while your fingers curl into a fist. This can also occur as a reaction to sudden, unplanned movements like when you cough or sneeze. Flexor synergy patterns after stroke are closely related to spasticity, or involuntary muscle firing. Spasticity occurs when there is a misfiring of signals between the brain and muscles, causing muscles to contract involuntarily, or spasm. As spasticity increases, so may the presence of flexor synergy patterns. Flexor synergy patterns of the upper extremity after stroke commonly involve these main movements: 60 synergy pattern 59 Neurological treatment techniques Facilitation Techniques: Rood approach Normalization of Tone & Maintenance Soft Tissue Length: Bobath,PNF, Purposeful movement : Task oriented, Constrain Induced Therapy, Neuro developmental technique (NDT), Neuro- INFRaH , Motor relearning 60 Facilitation Techniques Rood approach Facilitation and enhancement of muscle activity to achieve improved motor control are the key tenants to many of the techniques used in neurological rehabilitation, many of which also utilize neuroplasticity. The Rood Approach, theoretically based on the Reflex and Hierarchical Model of Motor Control, developed by Margaret Rood in the 1950s, provides the origin for many of the facilitation techniques used today in neurological rehabilitation today. Rood developed a system of therapeutic exercises enhanced by cutaneous stimulation for patients with neuromuscular dysfunctions. the greatest emphasis is given on exteroceptive applications such as stroking, brushing, icing, warmth, pressure, and vibration in order to achieve optimal muscular action. 61 Rood techniques Tapping - Tapping is the use of a light force applied manually over a tendon or muscle belly to facilitate a voluntary contraction“ Brushing Fast brushing - using a battery-operated brush on the skin overlying the muscle, is a therapeutic technique presented originally by Margeret Rood to facilitate movement responses and enhance static holding postural extensors. Icing - Ice can be used to facilitate a muscle response, which uses a combination of coolness and pain sensation to produce the desired response. 62 Rood approach Passive Stretching - Fast/Quick Stretch may be applied in a number of ways during neurological rehabilitation to achieve different effects. Joint Compression Joint awareness may be improved by joint compression which will lead to enhancing motor control. Receptors in joints and muscles are involved with the awareness of joint position and movement which are stimulated by joint compression. Joint compression can have both facilitatory and inhibitory effects. 63 Rood approach Muscle Vibration Muscle vibration has been used as a technique to reduce muscle tone and spasticity in individuals with neurological conditions. Vibrations of the muscle are thought to increase corticospinal excitability for high frequency 100 - 200 Hz and as well as inhibitory neuronal activity in the antagonistic muscle in low frequency 5 -50 Hz. 64 Proprioception Neuromuscular Facilitation PNF approach Proprioceptive Neuromuscular Facilitation (PNF) is a set of stretching techniques commonly used in clinical environments to enhance both active and passive range of motion in order to improve motor performance and aid rehabilitation. PNF is considered an optimal stretching method when the aim is to increase range of motion, especially as regards short-term changes. PNF helps to restore normal movement by focusing on the developing sequence of movement and how the agonist and antagonist muscles work together to produce volitional movement. PNF uses reflexive movement as a basis for learning more volitional movement. 65 Bobath approach Bobath concept is a problem-solving approach used in the evaluation and treatment of individuals with movement and postural control disturbances due to a lesion of the central nervous system. It is named after Berta Bobath, a physiotherapist, and her husband Karel, a psychiatrist/neuropsychiatrist, who proposed the approach for treating patients affected with Central Nervous System. They developed this approach for effective management of neuro- motor dysfunctions manifested by children with cerebral palsy (CP). Earlier, braces, passive stretching, and surgery were the most common forms of interventions. The Bobath concept provided a new reference that viewed children with CP as having difficulty with postural control and movement against gravity. 66 NDT Neurodevelopmental treatment is based on the premise that the presence of normal postural reflex mechanisms is fundamental to a motor skill's performance. The normal postural reflex mechanisms consist of righting and equilibrium reactions, reciprocal innervation, and coordination patterns. The release of abnormal tone and tonic reflexes seen in CP interfered with the development of righting and equilibrium reactions. 67 NDT Intervention strategies and techniques for NDT consist of therapeutic handling, facilitation, and activation of key points of control. Facilitation thro’ stretching , weight bearing. Bilateral movement. Inhibition to control spasticity in Reflex-inhibiting pattern RIP position RIP Reflex-inhibiting pattern (RIP)—A position that is used to inhibit spasticity by lengthening shortened muscles. Spasticity—Muscle tone that is higher than normal and resists passive stretching; also known as hypertonicity Key point control of proximal joints to influence limbs function. Certified course in HK for NDTA as specialized as NDT therapists. 68 Neuro-InFRaH approach Neuro- The unique name The word Neuro- It is integrative of Integrative of the approach was selected all systems of Functional was originated because this the person as Rehabilitation by the author to approach is well as all and Habilitation give an overall intended for information past (NEURO-IFRAH®) idea to the patients who are and present. is an approach reader regarding affected by originated by the scope of this lesions at the Waleed Al- approach. level of the brain Oboudi, MOT, stem and above. OTR/L based on NDT and applied in daily living as in OT. The word Integrative was selected to describe that this approach is integrative on all levels. 69 Neuro-InFRaH approach The word Functional means meets intended purpose or need, thus the word functional was selected because this approach is functional. The words Rehabilitation and Habilitation were selected because this is what we do in therapy. It encompasses many aspects of therapy,. One aspect of rehabilitation is to restore to the fullest physical, mental, social, vocational, economic status thus rehabilitation is not limited. However, our patients are not only re-acquiring skills they are learning new ones as well. Thus Habilitation occurs throughout alongside with rehabilitation. 70 Recovery for Extremities The Seven Brunnstrom Stages of Motor Recovery level description 1. Flaccid paralysis No reflexes 2. Some spastic tone No voluntary movement. Synergies elicited through facilitation. 3. Spasticity is marked Synergistic movements may be elicited difﬁcult voluntarily 4. Spasticity decreases Synergistic movements predominate 5. Spasticity subsides Can move out of synergies although synergies still present 6. Coordination and Trouble with more rapid complex movement patterns near movements. normal 7. Normal. 73 Motor Relearning approach Car & Shepher ( 1987) Motor relearning approach emphasizing the analysis of motoric problems in stroke patients as well as the process in the relearning of motor program. The motoric problems being analyzed summarized as: - Movement deficit or missing movement components - Atypical movement or unnecessary movement (pattern deviate from normal pattern ) - Compensatory movement (alternate movement substitute for normal movement pattern) 72 Assumptions of approach Motor relearning process make the assumptions on the construct of motor control : 1. regaining the perform of motor task is a learning process and people suffering from stroke have the same learning needs to go through the same processes as those who ae not impaired. 2. motor control take forms in both anticipatory and ongoing modes, and postural adjustment and focal limb movement are interrelated. 3. control of a specific motor task can best be regained by practice of the specific motor task in varies environment context. Sensory input related to the motor task helps modulate the action. 73 Essential mechanism of relearning When applying the model to intervention program, the essential mechanisms are: 1. elimination of unnecessary muscle activity associated with flaccidity or spasticity after stroke. Abnormal muscle tone either too low or high activities activate incorrect muscle causes unaffected side to move but no affected. ( inhibition) 2. practice of missing components weakness in stroke patient resulting from flaccidity of muscle inhibit movement so treatment should start from triggering varies type of contraction concentric or eccentric. ( facilitation) 74 Essential mechanism of relearning 3. task specific training application of functional movement in specific daily activity or task is the ultimate goal of training. Transference of training in similar tasks in different environment improve competence. 4. interrelationship between postural adjustment and the environment is dynamic process. The motor planning of the upper limb should be from proximal to distal. 5. feedback is essential for motor relearning. Intrinsic feedback included proprioceptive, somatosensory sense of muscle contraction, joint posture, sense of weight bearing and touch, Extrinsic involves verbal reinforcement, manual guidance , visual feedback and accomplishment if targeted task. 75 Essential mechanism of relearning 6. repeated practice is essential to regaining competence in task performance. A successful motor relearning program involves the practice of specific movement, encapsulating them in a schema, memorizing and retrieving them when the same class of movement is required in other situation. 76 Motor Relearning for Hemiparetic upper limb protocol (HK) Protocol developed by : Stroke focus Group. OTCOC, HA & Dept of Rehab Science HKPolyU ( based on early work in KH OTD) The goal of hemiplegic upper limb training for stroke patients is to maximize their potential to achieve greatest amount of muscle control and movement for functional activities after stroke given the limitation of brain damages. 77 Hemiparetic upper limb protocol Training protocol consists: 1. providing adequate stretching, positioning to maintain full functional ROM and patient education to prevent development if complication ie. Shoulder pain, shortening of soft tissue, muscle atrophy. 2. Retrain “ Body on arm” movement and bilateral activity to ensure truncal mobility and symmetry. Retaining trunk movement especially rotation and upper trunk initiated movement should be the integral part of the functional training. 78 Hemiparetic upper limb protocol 3. Practice of movement components and functional movement pattern : Reaching : forward, abducted across midline, backward. Alternate movement: elbow flexion/ extension, forearm supination pronation, wrist flexion/extension. grasp and release. 4. utilizing functional movement patterns in a task specific situation in real life environment. 79 Hemiparetic upper limb protocol Assessment Seven Functional Levels of the Functional Test of Hemiparetic Upper Extremity (FTHUE) Therapy protocol 80 Seven Functional Levels of the Functional Test of Hemiparetic Upper Extremity (FTHUE) –HK. level Minimum motion task level 1 No voluntary motion of Nil the shoulder, elbow or hand Level 2 Some beginning voluntary A Associated reactions motion of the shoulder & B Hand Onto Lap elbow 83 Level 1 level 2 壞⼿ Associated reactions Hand Onto Lap 84 Seven Functional Levels of the Functional Test of Hemiparetic Upper Extremity (FTHUE) –HK. level Minimum motion task Level 3 Mass flexion pattern in the C. Arm Clearance shoulder between 30 - 60 During Shirt Tuck degrees and at the elbow between 60 - D. Hold a Pouch 100 degrees, gross grasp of 3 - 5 pounds 85 Level 3 壞⼿ Arm clearance in dressing Hold a pouch 84 Seven Functional Levels of the Functional Test of Hemiparetic Upper Extremity (FTHUE) –HK. level motion task Level 4 Mass flexion > 60 degrees at the E Stabilize a Jar shoulder > 100 degrees at the elbow; some F Wringing a Rag elbow extension; 3 - 5 pounds of gross grasp and 1/2 to 3 pounds of lateral pinch 85 Level 4 壞⼿stabilize Stabilize a Jar Wringing a Rag affected hand 88 Seven Functional Levels of the Functional Test of Hemiparetic Upper Extremity (FTHUE) –HK. motion task Level 5 Beginning ability to combine G Eat with a Spoon components of strong mass flexion and strong mass extension patterns; H Box and Blocks greater than 5 pounds of grasp; greater than 3 pounds of lateral pinch 87 Level 5 Eat with a Spoon Box and Blocks 88 Seven Functional Levels of the Functional Test of Hemiparetic Upper Extremity (FTHUE) –HK. level motion task Level 6 Isolated control in the shoulder, I. Box on Shelf elbow and wrist against gravity; full extension of the shoulder, elbow, wrist and fingers; greater than 5 pounds of grasp; J. Drink from glass greater than 3 pounds of lateral pinch; controlled and coordinated movements may be poor and sluggish 89 Level 6 Box on Shelf Drink from glass 90 Seven Functional Levels of the Functional Test of Hemiparetic Upper Extremity (FTHUE) –HK. level motion task Level 7 Isolated control of all upper K Key turning extremity musculature with L1 Using good coordination and control chopsticks(D) L 2 Clip cloth peg (ND) 91 Level 7 壞⼿ Key turning Using chopsticks Clip cloth peg Dominant hand Non dorminant 92 Functional Test Hemiparetic Upper Extremity (FTHUE) 93 Assessment form Admission Discharge Follow Up Date : Date : Date : Level Task Pass Fail Time Pass Fail Time Pass Fail Time 1 Nil 2 A Associated reactions + - + - + - B Hand Into Lap + - + - + - 3 C Arm clearance during shirt tuck + - + - + - D Hold a Pouch + - + - + - 4 E Stabilize a Jar + - + - + - F Simulate “Wringing a rag” + - + - + - 5 G “Blocks and Box” + - + - + - H Eat with a Spoon + - + - + - 6 I Box on Shelf + - + - + - J Drink from Glass + - + - + - 7 K Key Turning + - + - + - L1 Use Chopsticks (dominant + - + - + - hand) L2 Clip cloth peg (non-dominant + - + - + - hand) 96 functional level & Focus of therapy Function Focus of therapy level I Correct alignment by ensuring proper positioning Safeguard affected limb against improper handling and prevent complication Improve awareness of affected upper limb II Re-educate Body on Arm movement. with weight bearing on forearm and extended arm. Train self assisted bilateral UL activities with clasped hands III Reinforce Body on arm movement with weight bearing and incorporated with remedial activities. Re-educate movement pattern components : reciprocal movement at single segment including grasp and release Prevent development of undesirable compensatory movement. 97 functional level & Focus of therapy Function level Focus of therapy IV Hand function Grasp and release training for hand function m finger and thumb extension Train functional arm reach Upgrade bilateral movement to shoulder level and across midline Use affected arm as active stabilizer and apply grasp and release in functional activities. V Tripod and pincer hand function training Coordinated arm reach for different planes and distance Integrate arm each movement with grasp and release of hand Re-educate bimanual use 98 functional level & Focus of therapy Function level Focus of therapy VI Enhance dexterity including isolated finger movement and in hand manipulation Enhance bimanual integration enhance strength and endurance Integrated arm reach with pinch action in functional task VII Enhance dexterity of hand, complex hand function and tools manipulation Build up strength, tolerance, speed and accuracy for full function integration Vocational training 99 Level I Encourage Proper Positioning Training Activities 1. Education on proper positioning: Functional Activities a) side lying b) supine lying 1. Rolling c) sitting position 2. Lying To Sitting d) use of sling 3. Sitting To Standing 2, Education on handling techniques 4. Forearm weight bearing on the a) during transfer or stand up table while incorporating the other b) adjusting sitting position upper extremity in functional tasks c)mobilization 3.Passive mobilization 5. Hand Washing d) scapular 6. Use the affected limb as passive e) gleno-humeral joint stabilizer in functional activities f) elbow and forearm g) wrist and finger 4. Forearm weight bearing activities a) on table b) on bed c) application of facilitation techniques 100 level I positioning Proper positioning for side lying Proper positioning for side lying on the unaffected side on the involved side Proper positioning in supine lying Proper positioning in sitting po 99 Level I Passive mobilization Scapular passive mobilization glenohumeral joint in flexion and extension Passive mobilization of elbow joint wrist & finger 100 level I Forearm Weight Bearing Activities Forearm weight bearing with Forearm weight bearing with lower-trunk initiated anterior lower trunk initiated lateral weight shift weight shift 101 level I Functional Activities rolling lying to sitting at the affected side forearm weight bearing in functional task sitting to standing 102 Level II activation of Ind. muscle Attempt facilitation techniques (e.g. vibration, quick stretch & joint approximation) for activating muscles contraction for isolate movements, Re-educate “Body on Arm” movements; weight shifting movements with weight bearing on forearm and extended arm; Train self-assisted bilateral UL activities with clasped hands. Start at table top level, 103 Level II treatment activities Training activities Functional activities 1. Extended arm weight bearing with 1. Hand onto lap when sitting upper-trunk-initiated movement 2. Bilateral cleansing of table 2. Extended arm weight bearing with 3. Position hemiplegic upper limb with lower-trunk-initiated movement extended arm weight bearing if 3. Skateboard possible beside hip during daily 4. Flat sanding activities 5. Stacking cones 4. Incorporate the weight shifting with weight bear on extended arm while the unaffected hand performing functional activities 104 Extended arm weight bearing with upper-trunk-initiated movement Extended arm in shoulder extension and external rotation 105 Extended arm weight bearing with upper-trunk-initiated movement Upper- trunk- initiated Upper- trunk- initiated anterior weight shift lateral weight shift 106 Level II remedial activities  Perform sanding on the Under the assistance of affected table with hand, move the skateboard with  shoulder & elbow flexion horizontal shoulder abduction & & extension adduction as well as elbow flexion & extension 109 Level II remedial activities Use OB help arm if more support for forearm is required 108 Level III Establish normal reaching pattern reinforce “Body on Arm” movement with weight bearing on extended arm with shoulder in slight extended and externally rotated position. Re-educate movement components: reciprocal movements at single segment including grasp and release action Prevent the development of undesirable compensatory movement 109 Level III treatment activities Training activities Functional activities 1. Weight bear on extended arm and 1. Clearance of arm for incorporate remedial activities. dressing 2. Re-educate movement components: 2.Pushing objects away from a) shoulder flexion and extension body b) elbow flexion and extension c) grasp and release 3.Incorporate relaxation technique in functional 3. Active shoulder and elbow movement activities so as to relax with skateboard muscle 4. Elevated sanding 5. Stacking cone 110 Level III treatment activities weight shift and object Movement re-education OB help arm transfer activities Shoulder flexion and extension 111 Level III grasp & release Grasp and release practice Assist release with tenodesis 112 Level III treatment activities Pre-stretch triceps to Elevated sanding stacking cone activiti enhance active elbow extension 113 Level IV Train functional arm reach with grasp and release Integrate movement components into functional arm reach Integrated arm reach in “Push & Pull” activities on table top Upgrade bilateral upper limb activities to shoulder level Use the affected limb as an active stabilizer in functional activities 114 Level IV activities Training activities Functional activities 1. Downward reaching 1. Stabilizing the bowl when feeding 2. Holding the toothpaste for screwing the 2 Shoulder board cap by unaffected hand 3. Table hockey 3. Wringing a towel 4.Lifting up the arm for passing through 4. Putty the sleeve of the upper garment 5. Catch 4 5.Carrying bags using hook grasp 6.Reaching for daily items 6. FEPS 7. UL Cycle 117 Level IV remedial Shoulder Board Downward Reaching 116 Level IV remedial Catch Four Table Hockey 117 Level V Encourage Coordinated reaching and pinching function Encourage coordinated arm reach in different planes of motion & for different distance incorporating more truncal movements & scapular protraction Tripod & pincer training Integrate arm reach movements with grasp & release actions in functional tasks Re-educate bimanual use, starting with simultaneous movements 118 Level V activities Training activities Functional activities 1. U.L. cycle 1. Feeding 2. Shoulder arc 2. Grooming 3. Computer activities with mouse 3. Dressing 4. Pegboard 4. Bathing 5. M.U.L.E. 5. Household 6. Pinch exerciser 6. Leisure 121 Level V remedial Upper Limb Cycle M.U.L.E. Pinch exerciser Pegboard Shoulder arc 120 Level 6 Enhance dexterity Integrated arm reach with pinch actions, including opposition, lateral pinch & dynamic tripod grip in functional task Enhance strength and endurance Bimanual integration 121 Level VI activities Training activities Functional activities 1. Pin box 1. Feeding: Chopsticks practice 2. Nuts and bolts 2. Personal hygiene: Screw toothpaste 3. Beads threading cap 4. Valpar 9: UE and whole body ROM 3. Dressing: Bilateral buttoning and lacing sample 4. Communication: Dialing phone, writing 5. U/L cycle or BTE practice if indicated 5. Household: use of scissors for gross cutting 6. Leisure: card games 122 Level VI remedial pin box beads and thread Nuts and bolts Valpar 9 BTE 123 level VII improving strength, tolerance, speed and accuracy Training Activities Functional Activities 1. Hammering 1. Use of chopsticks 2. BTE 2. Dressing 3. Mule 3. Communication 4. Heavy household tasks 5. Leisure 6. Specific job task training if indicated 124 Level VII remedial Hammering BTE Computing training or MULE 125 Q&A 126 Reference: 1. Stroke rehabilitation protocol 3 rd edition, OTCOC 2007, HA. HK 2. National guideline for Stroke 2nd edition, royal college of Physician, UK 3. Guideline on protective measure hemiplegic shoulder 2011 , OTCOC , HA HK. 4. Assessment and training of UL for Stroke 2000, OTD , KH. HA.HK 5. Reference in evidence- based OT practice in stroke,2015, medical subspecialty group OTCOC HA.HK 6. Balloons test manual, Thames Valley Test Company, Bury St Edmunds. 7. Stroke, Wikipedia 8. FTHUE, OTD, KH, HA. 9.Cerebral Vascular accident, P.844, Pedretti’s Occupational Therapy, practice skills for physical dysfunction. Seventh edition, Elsevier, Mosby., 10.Astrup et al. 1981, Lyden & Zivin 2000, Thresholds in cerebral ischemia - the ischemic penumbra., Stroke 1981 November –December. 11.Nudo RJ, Plautz EJ, Frost SB(2008) Role of adaptive plasticity in recovery of function after damage to motor cortex. Muscle Nerve, 2001, 24: 1000–1019 12. Carr JH, Shepherd RB. A motor learning model for stroke rehabilitation. Physiotherapy. 1989;75:372-380. 13.Bass-Haugen, J., & Mathiowetz, V. (2008). Optimizing motor behavior using the occupational therapy task- oriented approach. In M. V. Radomski, & C. T. Latham (Eds.), Occupational therapy for physical dysfunction (6th ed. ed., pp. 598-617). Lippincott Williams & Wilkin 14.Virgil Mathiowetz, Julie Bass Haugen.1994,, Motor Behavior Research: Implications for Therapeutic Approaches to Central Nervous System Dysfunction , AJOT, 1994 15. Sue Raine (2009) , Bobath Concept: Theory and Clinical Practice in Neurological Rehabilitation (pp.1 - 22) 16. Lacunar stroke, health Jade. healthjade.com 17. Teasell R, Hussein N, Foley N. (2013a). Managing the stroke rehabilitation triage process. In: Evidence-Based Review of Stroke Rehabilitation. Retrieved December 11, 2014 from http://www.ebrsr.com/. 18.Teasell R, Hussein N. (2013b). Background concepts in stroke rehabilitation. In: Evidence-Based Review of Stroke Rehabilitation. Retrieved February 11, 2015 from http://www.ebrsr.com/sites/default/files/Chapter3_Background- Concepts_FINAL_16ed.pdf. 19.Trompetto C, Marinelli L, Mori L, et al. (2014). Pathophysiology of spasticity: Implications for neurorehabilitation. BioMed Research International, vol. 2014, Article ID 354906. doi:10.1155/2014/354906. Retrieved January 15, 2015 from http://www.hindawi.com/journals/bmri/2014/354906/. 127 20.Francisco GE, McGuire JR. (2012). Poststroke spasticity management. Stroke. 2012;43:3132-3136. doi:10.1161/STROKEAHA.111.639831. Retrieved January 15, 2015 from 21. http://stroke.ahajournals.org/content/43/11/3132.full?sid=2904adf0-5b69-4919-96df-e765d2f35b39#sec-4. 21.Shumway-Cook A, Woollacott MH. (2012). Motor Control: Translating Research into Clinical Practice, 4th ed. Philadelphia: Lippincott, Williams, & Wilkins. 22.Takeuchi N, Izumi S-I. (2013). Rehabilitation with poststroke motor recovery: A review with a focus on neural plasticity. Stroke Research and Treatment, vol. 2013, Article ID 128641, 13 pages, 2013. doi:10.1155/2013/128641. Retrieved November 12, 2014 from http://www.hindawi.com/journals/srt/2013/128641/ 23. Activities of daily living, application of motor relearning and neuro-developmental treatment approach., working group on stroke rehabilitation co-orodinating committee for OT Hospital Authority, (2006) HKOTA 128

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