Transcript System theory

Stroke rehabilitation
Stroke rehabilitation
• Definition
– Teaching pt to manage his own life given
the limitations of damage of CNS
• Managing team involves Pt and family
for setting goals, planning treatment,
implementing clinical activities
Five major function of stroke
rehabilitation
• Prevention, recognition, management of
illness
• Training for maximal functional independence
• Facilitating psychosocial coping and
adaptation by pt and family
• Promoting community reintegration
• Enhancing quality of life
Recovery after stroke
• Neurological recovery
– Resolution of harmful factors
– Neuronal plasticity
Neuroplasticity -types of recovery
-Ability of nervous system to modify structural and
functional organization
Recovery of motor function
• L/EU/E and hand function
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L/E more complete recovery than U/E
Severe paresis of U/E…56%
Partial recovery of U/E…30%
Resolve of paresis of U/E…14%
• Return of tonevoluntary movement
• Proximal distal
• Mass movement (synergy)isolated
movement
The Basis of Motor Control
What is motor control?
• Defined as the study of the nature and the
cause of movement.
• Motor control refers to the study of posture
and movements and also to the functions of
mind and body that governs posture and
movement
• An area of study stressing primarily the
principles of human skilled movement
generated at a behavioral level of analysis
Theories of motor control
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Reflex theories
Hierarchical theories
Program theories
System theories
Neurological Rehabilitation
Models
• Muscle re-education model
• Neurotherapeutic model
• Contemporary task-oriented model
MOTOR CONTROL MODELS
REFLEX
HIERARCHICAL
SYSTEMS
MUSCLE
REEDUCATION
NEUROTHERAPEUTIC
FACILITATION
CONTEMPORARY
TASK ORIENTED
NEUROLOGIC REHABILITATION MODELS
REFLEX
• Human movements are the response to
stimulus.
Reflex limitation
• Human movements are not only initiated
by external stimulus but also by internal
drives
• It can not explain fast ballistic
movement
Hierarchical theory
• Human movements are controlled by central
nervous system which is organized in
hierarchical organized.
• Neurodevelopmental and neuro-facilitatory
theories, such as Bobath and PNF are belong
to this category.
• In this model, all low level behaviors are
primitive, immature, and non-adaptive, while
all higher level behaviors are mature and
appropriate.
Hierarchical theory
neuroanatomical
Postural reflex
development
Motor
development
Cortex
Equilibrium
reactions
Bipedal
function
Midbrain
Righting
reactions
Quadrupedal
function
Brain stem &
spinal cord
Primitive reflex Apedal
function
Hierarchical limitation
• It can not explain the dominance of
reflex behavior in certain situation in
normal adult.
• In fact, lower level center can influence
to the control of higher centers in neural
circuits.
• Sensory input pathways compare that
you wanted to do with what you did.
• Error detection and correction
mechanism can be a reflex-sending the
massages to the alpha motor neuron
and to the sensory cortex
• Efferent copy is the copy of the motor
out put from the spinal cord
• Afferent copy
Motor programming theory
• Movements are generated by central
motor program. This theory stress
“action” of central nerve system rather
than “reaction”
Planning and programs
• Motor planning
– Overall plans of learned tasks. Such as the action
sequences are produced by motor programs that
create smooth, fast, skilled action. Cognitive
aspect of movement.
• Motor programs are a set of muscle
commands
– That can be sent to the entire sequence can be
carried out in the absence of peripheral feedback.
• Programs are refined with practice by
feedback; critical part of learning.
System model of motor control
Environmental
system
Comparing
Regulation
system
system
Task
Goals
Sensory-motor
system
Commanding
system
Musculoskeletal
system
System theory
• Movement are not peripherally or
centrally driven but emerge as a result
of an interaction among many systems,
each contributing to different aspect of
control.
• There are no higher or lower level of
control because there are many
systems that distribute control at the
same level.
• Clinical advantage: the flexibility and
adaptability of motor behavior in a
variety of environmental conditions.
• Limitation
– Definition and testability of this model too
abstract and distributed
Equilibrium
BALANCE
Perception
of orientation
Predictive
Central set
EQUILIBRIUM reaction
Sensory
organization
Righting reaction
Tonic neck
Balance
Motor
coordination
Environmental
adaptation
Musculoskeletal
system
reflex
Stretch
Higher center (+)
Muscle
tone
(-)
X
Input
Muscle
-spindle
Reflex
Lower
center
Muscle
Activation
patients
Passive
elastic
properties
TONE
Response
To stretch
TONE
Kinematic
patterns
Muscle fiber
properties
Output
Mono
-neurons
Muscle Stiffness
Access to
Conscious
control
Motor relearning program
• Carr and Shepard
• Emphasize functional training for
specific tasks, such as standing and
walking, and carryover of those tasks
Occupational therapy
• Improve function of U/E
• Neurological, functional, cognitive,
perceptual assessment is essential
• Functional assessment in pt’s own
home environment is benefit
Can proprioception really be
improved by exercises?
Ashton-Miller JA, Wojtys EM, Huston LJ, Fry-Welch D.
Knee Surg, Sports Traumatol, Arthrosc (2001) 9: 128-136
Can proprioception really be
improved by exercises?
• 관절마다 역치는 다르다.
• Proprioceptive receptor의 정보는 두 가지
경로를 거쳐 중추신경계로 전달된다.
• 구심성 정보는 원심성으로 조정된다.
• 중추신경계의 mechanism
• Skill training이 proprioception을 향상시
키는가?
• Attention의 역할
Management of vertigo
Neuromuscular stimulation
(FES)
• Surface neuromuscular stimulation enhance
U/E or L/E recovery of acute stroke survivors
• Stimulation site
– U/E: deltoid, supraspinatus, EDC
– L/E: TA, peroneal nerve
• Stimulation time: 30~60 min
• Stimulation intensity: to provoke full ROM of
joint
EMG-biofeedback
• Focus on neuromuscular reeducation
• Recording surface EMG from test
muscle
• Using auditory or visual display of signal
as feedback to pt on ongoing status of
muscle
Constraint-induced movement
therapy (CI)
• To overcome learned nonuse
• Force hemiparetic arm by constraining
the healthy arm
Model for Overcoming Learned Nonuse
Constraint-Induced Movement Therapy
Learned non-use;
Masked recovery
of limb use
Increased
motivation
Use-dependent
cortical
reorganization
Affected limb
use
Further practice
and
reinforcement
Learned non-use
reversed;
Limb used in life
situation
permanently
Positive
re-enforcement
Use dependent
cortical
reorganization
Further practice
and
reinforcement
Constraint Induced Movement Therapy
 CIMT is a new approach
to the rehabilitation of
movement in a
hemiparetic limb after
stroke.
 Most work thus far has
focused on UE
rehabilitation in chronic
stroke patients who
have minimal to
moderate involvement
of the affected extremity.
Constraint Induced Movement Therapy
The involved UE is taken
through extensive massed
therapy over several
consecutive days.
 “Shaping” therapy for
motor learning is provided
in a supervised
therapeutic setting for 6-8
hours per day.
 Several hours of forceduse in daily living skills
outside of the rehab
setting (also 90% of the
day for 10-15 days).
Painful hemiplegic shoulder
• More frequently ass with spasticity than
flaccidity
• Occur up to 84% of stroke pt
• As early as 2weeks poststroke, but usually
2~3mo
• Good shoulder function is prerequisite for
successful transfer, maintaining balance,
performing ADL
Painful hemiplegic shoulder
• Resulting from
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Glenohumeral subluxation
Impingement syndrome
Rotator cuff tear
Frozen shoulder
Brachial plexus injury
Reflex sympathetic dystrophy (RSD)
Bursitis, tendinitis
Central pain
Glenohumeral subluxation
• 17~64% of pt
• Weight of arm pulling down humerus
– Supraspinatus, deltoid flaccid or weak
• Glenoid cavity facing downward
– Weakness of scapular muscle
• Role of shoulder subluxation in
generatiing hemiplegic shoulder pain
has been debated
Spastic shoulder
• Spastic muscle imbalance is cause of
shoulder pain
• Cause pain by
– Constant tension of agonist in synergy
– Pectoralis major, subscapularis
– Internal rotator predominate after stroke
• Treatment
– Stretching of shoulder depressor and
internal rotator to minimize spasticity
– Phenol injection: subscapular nerve block
– Botulinum toxin injection
RSD
• Incidence
– Clinically diagnostic: 12.5% of pt
– Triphasic bone scan:25%
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1~4mo post stroke
Pain in shoulder followed by wrist, hand
Painful LOM of wrist, MCP, PIP joint
Spare elbow joint
Progress to dry, cold, atrophied hand
• Management of RSD
– Prevention
• Early ROM exercise
– Exercise
• Frequent active and passive ROM exercise
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Modality
High dose oral corticodsteroid
SGB (stellate ganglion block)
Sympathectomy
• 제1기(손상후 2~3개월 이내)
– 손가락이나 하퇴, 족부의 피부 홍조, 종창, 뚜
렷한 자발통, 경증의 관절 구축
• 제2기(3개월 이후)
– 종창의 쇠퇴경향, 피부 위축경향, 관절구축 증
강, 반점 위골 위축
• 제3기(9개월 이후)
– 자발통의 쇠퇴경향, 뚜렷한 피부위축, 뚜렷한
관절구축
Painful hemiplegic shoulder
• Treatment
– Arm sling
• Bobath sling: ambulator
• Hemisling: ambulator, W/C ambulator
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Laptray: W/C ambulator
Oral medication, steroid injection
Physical modality
Aggressive and consistent ROM ex
Functional electrical stimulation
Spasticity
• Definition: velocity dependent increase of
muscle stretch reflex with increased DTR
• Goals of spasticity management
– To improve ADL, mobility, ease of care, sleep,
cosmesis
– To prevent pressure area developing
– Reduce pain
– To allow stretch of shortened muscle,
strengthening of antagonist muscle, proper
orthotic fit