Neuro-Rehab

1. STROKE
REHABILITATION
Dr. N. Wanjiru PhD PT

2. Common impairments after stroke
 Sensory loss
 Visual problems
 Weakness UL, LL & face
 Altered tone
 Gait, balance and coordination
 Aphasia
 Apraxia of speech
 Cognitive impairment
 Dysarthria
 Dysphagia
 Perceptual impairments.

3. The main problems
The main symptoms
Loss of foot/ankle control
Total knee instability
Low muscle tone/ instability in
trunk and shoulder
Strong spasticity's
Stiff knee, foot strongly in
plantar extension (pes equinus)

4. SYNERGIES
 Mechanism where group of muscles work together to execute a
specific task.
 The task require more than one muscle, joint or more than one
group of muscles (command key in the brain)

5. Abnormal synergies
 Flexor Synergy
 Extensor Synergy
 Mixed Synergy: combination of flexor synergy & extensor
synergy

8. Compare synergyies
 Shoulder elevation & retraction of flexor synergy is stronger than
the shoulder protraction & depression of the extensor synergy
 Shoulder adduction and internal rotation of the extensor
synergy is stronger than the shoulder abduction and external
rotation of the flexor synergy
 Elbow flexion of the flexor synergy is stronger than the elbow
extension of the extensor synergy
 Forearm pronation of the extensor synergy is stronger than
supination of the flexor synergy

9. Mixed synergy
 Paterns is derived from combining the stronger components of
flexor synergy and extensor synergy
 Shoulder elevation and retraction, shoulder adduction & internal
rotation, elbow flexion and forearm pronation.
 Hemiplegic patient can not perform isolated movement when
bound by this synergies

10. Con…
 UL flexor synergy is initiated by shoulder elevation and elbow
flexion (muscle recruitment)
 The rest of the muscles of the synergy follow this activation
 NB: Some stroke cases might display shoulder hyperextension
while perfoming the UL flexor synergy.

11. Con…
ANSWERS WHY:
 Few movement are easily performed and others are diffucult to
perform
 Stroke find it difficult to extend the elbow, abduct the shoulder,
supinate.
 This is so because this are the weaker components of the flexor
and extensor synergies

14. BASIC LL SYNERGIES
 Strongest component of flexor synergy;
 Hip Flexion
 Strongest component extensor synergy;
 Hip Adduction
 Knee extension
 Ankle planterflexion, & inversion

15. MIXED SYNERGY
 Hip: Flexion, adduction
 Knee: extension
 Ankle & foot: planterflexion inversion

16.  NB: In LL, the extensor synergy predominate and is more stronger
than the flexor synergy.
 With disinhibition of the cortex, the cortex is not able to control
the midbain and the brainstem
 Hence unregulated descending motor pathways originating
from the midbrain and the brainstem

17. Con…
 Rubrospinal track are responsible for increasing the flexor tone of
the upper extremity
 (Rubrospinal track does not extend beyond thoracic spine)

18. Con…
 Vestibulospinal tract, controls the extensor tone of the UL & LL.
 With disfunctional cortex, we have overactivity of vestibulospinal &
rubrospinal tracks
 The efferent motor discharges from the two pathways remain
unregulated hence excessive contraction in the target muscles

19. Con…
NB:
 Ankle eversion is not involved in any of the synergy pattern, hence
it is difficulf for hemiplegic patient to perform an evertion mvt.

20. Hemiplegic gait

21. Con…
■ When a patient tries to take the limb forward, along with hip
flexion, we see hip adduction, knee extension, planter flexion and
inversion
■ Understanding synergies will answer many questions:
 Why there are challenges maintaining upright balance
 Why there is less weight bearing on the hemiplegic side
 Why in a hemiplegic gait, there is increased swing time and
decreased stance time on the affected time
 Why hemiplegic patient struggles with activation of knee
flexion & ankle dorsiflexion

22. STROKE RECOVERY
 Stereotypic sequence of events takes place during the process of
recovery post stroke
 The sequence are devided into 7 stages
 Each stage has certain key characteristics and features

23. STAGES OF RECOVERY
Stage 1:
 Recovery begins with a period of flaccidity immediately following
acute episode.
 No movement of limbs can be elicited, complete areflexia.
Stage 2:
 Development of spasticity in UL & LL.
 Spasticity develops fast in the strongest component of flexor and
extensor synergies. Biceps & quadricep

24.  Basic limb synergies get initiated as associated reaction
 When hemiplegic patients puts extra effort on the normal side,
there is reflexive stimulative reaction on the basic limb
synergies on the paralytic side)
o Homolateral limb kinesis
o Raimeste’s Phoenomenon
 Some patient can exhibit voluntary movement on the paralytic side

25. Stage 3:
 Spasticity reaching its peak
 Gains voluntary control of movement synergy although full range is
not developed.
 Considered as a semi-voluntary control
 Patient can initiate movement, but has no control over the outcome
of the movement (synergy bound)

26. Stage 4:
 Patient can initiate movement outside the limb synergy
 Some movement combination that do not follow the synergy
are mastered first with difficulty & later with more ease.
 Spasticity begins to decline but can still interfere with
movement outside synergies

27.  Patient has to use more energy to produce movement outside the
basic limb synergies
 Spacticity declines, movement becomes easy
 Test 3 key movement to determine the patient is in stage 4 of
recovery

28. Upper Limb
1. Hand behind the body
2. Pronation supination with elbow flexed at 900 and adducted
 Indicates disociation of supinator from biceps muscle
3. Upper limb horizontal elevation with elbow extended
 Indicates dissociation of pectoralis major muscles from triceps

29. Lower Limb
 Movement outside the synergies are;
 Knee flexion beyond 900
 Ankle dorsiflexion without lifting the foot off the ground
NB: Not always does the upper and the lower limb fall in the same
stage of recovery simoulteneously

30. Upper Limb
 Isolated knee flexion on the
paralytic limb with hip
extended or in neutral
position
 Perform isolated ankle
dorsiflexion

31. Stage 5:
 More difficult movement are learnt as the basic limb synergy lose
their dominance over motor roots.
 Variety of mvt are mastered from the paretic side, as synergies
disappear
 Spasticity further declines

32. 3 key movement test to determine the patient is in stage 5 of recovery
 Upper Limb
 U/L horizontal elevation beyond 900 - 1800
 U/L abduction to 900 with elbow extended
 Supination pronation in U/L abduction to 900 with elbow
extended

33. Stage 6:
 Disappearance of spasticity, individual joint movement become
possible & coordination approaches normal.
 Wide spectrum of movement combination possible
 Normal motor function is restored

34. Stage 7
 Restoration of normal motor function.
 Patient becomes completely independent
 Perfoms all ADL in a purposeful and coordinated manner

35. MANAGEMENT
 Patients’ (and carers) needs and wishes are identified and
quantified
 Goal setting: goals are defined for improvement
(long/medium/short term)
 Intervention: to assist in the achievement of the goals
 Re-assessment: progress is assessed against the agreed goals.

36. ACUTE STAGES
Positioning
Five main positions recommended are:
 Lying on the unaffected side
 Lying on the affected side
 Lying supine.
 Sitting up in bed.
 Sitting up in a chair.

37. Positioning strategies
 In supine
 In side lying on normal side
 In side lying on affected side

38. Post stroke Shoulder
 Shoulder pain is the most common complication post stroke with
17-64% within the first 3 weeks
 What makes the shoulder susceptible????
 Flaccidity in early stages of hemiplegia leads to compromised
glenohumeral intergrity
 Static stability of the shoulder is lost
 Leads to inferior anterior migration of the head of humerus
(Sulcus sign)
 Abnormal stretch of the periarticular structures of the shoulder
joint due to ischeamic changes hence pain & infl

39. Management of shoulder
complication
 Shoulder support (right shoulder support at the right time)
 Prevent subluxation & maintain glenohumeral integrity in a
stroke patients.
 Should be cosmetically sound & allows the upper limb
available for exercise sessions
 Prevent pull of shoulder by downward acting forces
 Maintain glenihumeral integrity during ROM exercises of UL

40.  Should not facilitate flexor spacticity in hemiplegic upper limb.
 Arm sling facilitates flexor spacticity in biceps MMs & adductor
spacticity in pectoralis major MMs
 Become challenging performing shoulder ROM

41. Rehabilitation targets
■ Reduction of pain, reposition of shoulder luxation, high
compliance
Fast as possible regain of stability and function
o Motor relearning needs repetition
o Needs specific tasks
o Needs compensation movements

42. 18
Page 18
Omo Neurexaplus
18
• Stress-reducing and stabilizing
shoulder orthosis
• Improves body posture and
gait

43. Omo Neurexaplus
• Reposition of the shoulder joint
• Cover the loss of muscle stability
• Minimizing the weight of the arm
• Prevents spastic episodes
• Free use of the arm
• Alleviation of pain of up to 50%

44. Reposition

45. Effect with Omo Neurexa plus
The lower soft
calf is fixed by
the dog skin
material and
the silicon
strap to
prevent
slipping and
rotation. But
there is a
movement
between soft
tissue and the
orthoses in
both
directions!
The Manu Neurexa plus
instead of the lower soft
calf; controls the rotation
and the relief with an
orthotic rigid frame.
Because of the anatomical
structure and the
correlation of movements
from Hand to Wrist and
Elbow the outer rotation is
stronger. The relief of the
arm is more effective
because of the
Hand/Thumb structure.
Omo Neurexa plus
upper part section
Manu Neurexa plus
connection buckles
Therapeutical result: The repositioning of the shoulder is more effective and the outer rotation of
the arm to prevent or work against spasticity is stronger. Therefore the therapeutic outcome is
higher!
and Manu Neurexa plus

46. Comparison of gait

47. QUALITY OF A GOOD SHOULDER SUPPORT
 Should provide stability to the glenohumeral joint
 Should be cosmetically sound, & can be worn under the
clothes
 Should permit ROM exercises or weight bearing activities
 Easy to wear and remove

48.  Proper handling & positioning of shoulder joint
 NMES, gentle mobilization (grade 1 & 2)
NB: The following modes of treatment are contraindicated
 Use overhead pulley
 Heat therapy

49. Managing Limb Synergies
 Neuroplasticity
 Brunnstrom Approach
o Execute normal movement patterns over and over again for
reorganaisation of the brain.
o The remaining neurons can take over and normalise the
movement pattern by inhibiting the abnormal muscle
synergies when necessary

50. STEP 1
 Introduce a new movement outside the involved synergies
 Remove the shoulder abduction component and replace with
shoulder adduction (component of the extensor synergy)
STEP 2
 Design an exercise which involves this new movement intergrated
in task oriented activities
 E.g. Pt use the paralytic hand to touch the opposite hand
 Move upwards: the shoulder, ear, forehead, and back of the head.

51. STEP 3
■ Therapist should demonstrate the new combination of movements
by passive movement.
■ Patient remains as relaxed as possible and the therapist
demonstrates.
■ This mvt can take place in space or via the sliding mvt on the
contralateral side.

52.  All these mvt involves shoulder adduction & elbow flexion
 The brain registers the new combination of mvt, goal directed, and
acompanied by sensation of touch.
 Increases sensory impulses input to the brain
 Increases motor output in a more purposeful manner
 Brunnstorn also recommend stroking/ rubbing with paralytic arm,
increases sensory awarenesss hence motor output

53. STAGE 4
 Use of hold after positioning technique
 Never encourage the patient to produce a motion from the
beginning of the range
 Start from end range
 Passively, place the limb in end range position
 “Hold your arm here, do not let me slide it down
 NB: The technique is similar to PNF

54.  New pattern needs to be put in end range.
 All the muscles that are supposed to act to produce that motion will
remain in a shortened position
 As a result the muscle spindle remains short
 When the instructions are given to the patient: “Hold the arm and
do not allow me to slide it down”
 Pt tries to maintain the position of the hand against the push from
a therapist

55.  A contracting spindle stretched, further strenghtening of stretch
reflex of the pattern that we want to strengthen (secondary ending
stretch)
 Train in small end range first, then increase gradually as patient
improves
 Utilizes the three isotonic contraction
 Eccentric contraction
 Concentric contraction
 Isometric contraction
 More and more functional activities are trained using combination
of movement e.g combing hair,

56. Sensory Re-education
 A cognitive behavioural therapy technique
 Helps the patient to meaningfully interpret the altered neural
impulses reaching conscious level after the altered sensation area
has been stimulated.
 The repetitive neural input produces plastic changes(plasticity) in
the somatosensory cortex

57.  Sensory re-training does improve both the patient’s cognitive and
adaptive response to stimulation of the affected skin region
 This functional reorganisation of the brain is a natural process and
depends on the brain´s capacity to adapt when the body sends
new signals.

58.  The exercises should be done for a few minutes several times a
day.
 Performing sensory re-education exercises for a short period of
time, 4 to 6 times per day on a daily basis, is more effective than a
longer, less frequent protocol
 Start the training soon after an injury when the patient is stable
enough to receive therapy

59. STAGES OF RETRAINING
 Stage 1: Localization
 The intent is to re-educate constant vs moving touch
perceptions.
 A greater stimulus intensity may be necessary for the patient to
differentiate constant from moving touch
 Intensity should never be so great as to evoke injury

60. Stage II: Texture and shape discrimination
■ The intent is to re-educate the directionality of movement
perceptions of the patient.

61. Equipments
 Brush
 Piece of cloth
 Ball
 Soft towel
 A container of lotion
 Massager

62. Prodcedure
 Place the affected part of the body on a couch
 Use the soft brush and stroke deeply from the shoulder downward
to the finger/hip joint to the foot
 Turn the limb and quickly perform mild stroke backwards to the
shoulder/hip
 Do the same with different textures
 Ice stroking

63.  Positioning hemiplegic side towards door or main part of room
 Weight bearing ex & Joint approximation techniques

64. Con…
 Stroking with different texture fabrics
 Pressure application
 Improve other senses like use of visual & auditory

65. Spasticity
■ Interventions to reduce spasticity should be considered when the
level of spasticity interferes with ADLs
■ Routine use of resting splinting of the upper limb to reduce
spasticity in the wrist and finger flexors following stroke is not
recommended.
■ Botulinum toxin type a (Botox®) use for spasticity causing pain or
interfering with physical function

66. Tone & Mvt recovery in flacid state
Brunnstrom Aproach (stage 1 & 2 of recovery)
 Key point (all exercises are meant to)
 Increase background tension in muscles
 Facilitate reflexive movement in falccid muscles of UL & LL
 Achieve in 3 strategies

67. Postural reflexes
ATNR & STNR
Associated reaction
Raemiste’s
Phoenomenon
3 Strategies
Local Facilitation:
Vibration, tapping
e.t.c

68.  Patient voluntary effort with the 3 strategies will increase the
background tension.
 Raemiste’s adduction
 Utilize local facilitation techniques e.g. tapping, rubbing (stimulate
muscle spindle)
 Exercise variation

69. Ex in flaccid stage LL
 Aim: increase the background tension of the hip muscles and
gaining reflexive movt
 Patients takes the normal knee into flexion, therapist takes the
affected limb in to flexion and support it at the knee to avoid a fall
 1st mvt is the hip adduction mvt on the paralysed limb. Use the
Raemiste’s adduction phoenomenon.
 Therapist places one hand medially on the nonaffected joint
proximal to the knee joint while maintaining support on the affected
joint

70.  Ask the patient to produce strong effort from the hip adductor
muscle of the non-affected hip
 The therapist will resist the motion in such a manner that no or
very little mvt is produced on the normal side
 While the patient generate this mvt on the normal side, we will see
a reflexive increase in the background tension and reflexive mvt
setting inn on the paralytic side lower limb
 The limb that was falling outward will start moving in adduction
direction

71. ■ Therapist can also do rubbing and tapping over the adductor
muscles to further generate background tension by stimulating
muscle spindle
■ The therapist can also have exercises in which the therapist keeps
his hand between the knees and ask the patient to generate a
strong contraction from the normal adductor muscles

72.  When the knees approximate to each other, then the therapist
takes them to the paralysed side.
 Instructs the patient not to allow the fall outwards
 The resistance is maintained throughout the motion

73. Ex in flaccid stage UL
■ Gain midrange elbow flexion in paralytic U/L
 Utilize local facilitation techniques
o Tapping, rubbing (stimulate muscle spindle activities)
o We see a reflexive activities in hemiplegic elbow joint
■ Gainning elbow extension in paralytic
 Utilise associated reactions to facilitate tone on the weaker
side using imitation kinesis
 Performing the same movt on the normal side with resistance
as intended to achive of the affected side

74.  Use a therapist to resist the forcefull contraction of triceps
muscles on the normal side
■ Use of functional task oriented activities to increase patients from
day one of therapy program
■ Therapist can use a mobile in the hand of a patient, passively take
it UL in the end range
■ Turn the head in the opposite direction; we use postural reaction
■ The other hand of the patients imitates the same activity

75. ■ Therapist resists the mvt on the normal side of the patient.
■ The patient is instructed, “do not let me take the mobile away from
you
■ Once the patient starts getting strong contractions of the normal LL
group of muscles

76. ■ The patient is instructed to hold the position from the weaker side
close to the face
■ Patient produces isometric to eccentric contraction of the
muscles on the affected side even during the flaccid face

77. ■ Flaccid muscles:
– Use of NMES
■ Spastic muscles
 Upper extrimity:
 Lower extrimity
 Use of orthoses:

78. Con…
 Sustained stretch
 Weight bearing exercise

79. LOWER LIMB REHABILITATION
 Abnormal synergies Mgt
 Gait-oriented training
 Ankle foot orthosis
 Repetitive task training
 Increased intensity of rehabilitation

80. Gait training
 Functional electrical simulation for treatment of footdrop.
 Treadmill for gait training for patient that are independent in walking
at the start of treatment.
 Repetitive Task Training: when the aim of treatment is to improve
gait speed, walking distance.
 Walking Aids : Should be considered only after a full assessment
of the potential benefits and harms of the walking aid.

81. Ankle-Foot-Orthosis
 Has an immediate improvement in reduction of abnormal
synergies
 Improves on walking speed, efficiency or gait pattern and
weight bearing during stance.
 Reduces spasticity, & chances of tendon shortening are
reduced
 In patients prescribed AFOs, regular re-assessment is
recommended for long term effects.

82. “Simply GoOn!”

83. 06.06.2023
Ground reaction Force influencing AFOs
Technical solutions
State of the art fitting solutions

84.  Initial gait training between parallel bars
 Proceed outside bars with aids & then without aids
 Walking forward, backward, sideways & in cross patterns
 Partial Body-Weight-Supported Treadmill Training (PBWSTT)
with higher speed improves overall locomotor activity &
overground speed
 Proper use of orthotics

85. POSTURE
 Spastic patterns can involve flexion & abduction of arm, flexion
of elbow, & supination of forearm with finger flexion.
 Hip & knee extension with ankle plantarflexion & inversion
 Protracted & depressed shoulder, scoliosis & hip hiking