dr. nirmal surya, md,dnb, fian
TRANSCRIPT
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DR. NIRMAL SURYA, MD,DNB, FIAN
President, Indian Federation of NeurorehabilitationPresident Elect, AOSNR
President Elect, Indian Academy of NeurologyMember at Large, Presidium, WFNRChair, ICHA Telemedicine Academy
EC Member, ISA(2018-2021)President, Xth WCNR2018
Chair, Developing World Forum, WFNRRVP, South Asia, WFNR
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Movement disorder: Term used for Physical sign of abnormal movement in absence of weakness The syndrome that causes such motor abnormalities
Movement disorders disrupt motor function by Abnormal, involuntary, unwanted movements (hyperkinetic movement
disorders) Curtailing [restricting] the amount of normal free flowing, fluid
movement (hypokinetic movement disorders) hypokinetic movement disorders are accompanied by abnormal states
of increased muscle tone Pathology is in basal ganglia
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Insufficient movement
Akinetic, hypokinetic or bradykinetic
syndromes
Too much movement
Jerky movements
• Myoclonus (including excessive startle)
• Chorea (including ballism)• Tic disorders
Non-jerky movements
• Dystonia (including athetosis)• Tremor
Parkinson’sdisease
Abdo, W. F. et al. Nat. Rev. Neurol. 6, 29–37 (2010); doi:10.1038/nrneurol.2009.196
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Managing Problem associated with Movement disorder like Gait,posture control,fall, transfer,function and general therapy
Exercises Movement strategy Training
Chair, Developing World Forum, WFNRRVP, South Asia, WFNR
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hands-on impairment-level intervention to improve body level performance
Provision of information and education –to facilitate informedchoice and optimize self management ability
Managing the environment-eg: adapting facalities, to reduceeffort or risk, or to remove the need to undertake a problem task together
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Skill level intervention
Knowledge level intervention
Attitude level intervention
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Assess/observe/monitor/measure changes Enhance/ maintain/restore movement/mobility/activity
level/physical activity/participation in social roles Promote independence/slf care/adaptation to new social roles Promote optimal Medicational Management Prevent secondary complications like falls, pain,skin lesions etc. Optimize bladder and bowel function Facilitate coping and care giver Provide palliative care if required Collect evidence on outcomes and effectiveness of care
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Dysarthria: hypokinetic ( predominantly seen with PD) Hyperkinetic a) slow like dystonia b) fast like choreaAssesment: word/sentences/paragraph/picture description etcTreatment : hypokinetic or hyperkinetic
role is limited in chorea/dystoniaAAC : Alternate and Augmentative communication RoleCognitive - Linguistic disorders: Assesment / Managementcompensatory and behavioural approaches/ functional training
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Cough/choaking/wet and gurgly voice after food/ sialorrhea or excessive drooling and weight loss
Assesment of swallowing disorder; bedside/ FEES Management: compensatory strategies: consistency of fluid and
food/ Bolous modification/ portion/postures and maneuvers(chin tuck or down)
Supraglottic swallow/ effortful swallow/Mendelssohn maneuver)
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Speed of processing and motor prepertaion(HD and dystonia ) Temporal Processing Internal V/Sexternal control of attention and action Automatic V/S controlled performance of action Concurrent performance: doing two thing at once Inhibition of prepotent responses and response selection under
conflict Procedural and skill learning
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Dystonia - a syndrome describing a special form of muscle hyperactivity characterised by
Sustained or intermittent muscle contractions causing
Abnormal, often repetitive movements, postures, or both
Dystonic movements are typically patterned, twisting, and may be tremulous
Dystonic muscle hyperactivity is often painful
Rehabilitation of Movement Disorders 2016 67-81
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Dystonia is a movement disorder characterized by abnormal musclecontractions that can be worsened by stress.
The result is co-contraction of inappropriatemuscles and overflow of electromyographic activity, alongwith marked difficulty in switching the component movements of a complex task.
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Physiotherapy
Occupational therapy
Speech therapy
Psychotherapy
Use of orthoses
Counselling of the patient and
their family
The combination of methods applied and their frequency and intensity depend on the severity of the patient’s individual dystonia
Rehabilitation of Movement Disorders 2016 67-81
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Botulinum Toxin(BT)therapy is the treatment of choice for cervical dystonia
DBS is an alternative
Anti-dystonic drugs and adjuvant drugs may be used at the end of the BT treatment cycle
When BT therapy is used, physiotherapy is necessary in most patients
Behavioural therapy is mainly based on electromyographic feedback techniques.
Rehabilitation of Movement Disorders 2016 67-81
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BT therapy is the treatment of choice for Blepharospasm
Levator suspension operation connecting the upper eyelid to the frontalis muscle via a Goretex® string is helpful
Deep brain stimulation (DBS) is principally effective in blepharospasm
Rehabilitation of Movement Disorders 2016 67-81
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Laryngeal dystonia (spasmodic dysphonia) is an extremely rewarding indication for BT therapy
Rehabilitation of spasmodic dysphonia is usually applied as speech therapy
• Stress• Voice overuse • Unfavourable situations including talking over the phone and noisy places
General recommendations include avoidance of
Rehabilitation of Movement Disorders 2016 67-81
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For writer’s cramp and musician’s cramps BT is the treatment of choice
The concept of re-learning normal movements by improving independence and the precision of individual finger and wrist movements
Occupational therapy is even more widely used and employs a large number of different strategies
• Biofeedback techniques • Habit reversal training • Constraint-induced motion therapy or sensory motor retuning• General training exercises • Supinator writing practice
Behavioural therapies include
Rehabilitation of Movement Disorders 2016 67-81
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Current evidence on feasibility, validity and cost effectiveness of Rehabilitation in Dystonia is limited
Large variety of interventions described but not many testedin controlled manner
Methodological shortcomings of many published study Complexcity warrant inter-professional approach to optimize
QOL and reduce impairment and disability
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Rehabilitation of Chorea
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Chorea is a movement disorder that is characterized byirregular, rapid, flowing, nonstereotyped and random involuntary movements. It maybe a part of Huntington’s disease which is characterized by triad of motor, cognitive and emotional disorders. Relatively early involvement of cognition makes rehabilitation of HD a challenge. Therapeutic programs that require motivation and skill learning are not effective.
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Rehabilitation strategies include exercises to improve strength, aerobic fitness, flexibility, coordination, postural stability and efficiency of breathing and coughing. Cognitive retraining can be started early in the rehabilitation. Therapy that is individualised but conducted in a group setting has been shown to be effective. Unlike other gait disorders, prescription of gait aids may not useful because of difficulty in performing dual tasks.
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PSYC4080 6.0D Movement Disorders 26
Hereditary - dominant gene on Chromosome 4 Causes a degeneration of the caudate nucleus and putamen
(basil ganglia) GABA and Ach neuron loss Uncontrollable movements, usually jerky limbs Progressive, leading to death (due to complications from
immobility) Symptoms start in 30s-40s No Medical treatment for the disorder Rehabilitation as support therapy to prevent complications
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Rehabilitation in Ataxia
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Improvement of Proprioception Propioceptive neuromuscular facilitation Rhythmic stabilisation Slow reversal technique Resistance exercises
Gait exercises on soft ,hard ,inclined, uneven surfaces Plyometric exercises Minitrampoline exercises Feldenkraise techniques Alexander techniques
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Mat activity of PNF Static stabilisation Dynamic stabilisation Bridging Weight shifting Tandem gait ,Forward walking ,backward walking Soldiers gait ,Stand alone marching Tai chi ,Yoga Coordination Dynamic therapy
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StaticDynamic
Intensity=sensory or time
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Bridging Rolling Prone on all four limbs
Kneel walking Half kneeling Standing
Regular Exercises on Mat
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Sitting on vestibular ball
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Prone on vestibular ball
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When people present with the early signs and symptoms of ataxia, they are likely to engage in unsupervised activities in an attempt to minimize their symptoms.
Guidance of a skilled professional is key at the beginning of any program to incorporate activities that are suitable for these patients.
Physical therapy should not be discontinued in advanced stages of disease in dependent, bedridden people
Passive/assisted mobilization and correct positioning are essential at these stages to maintain the same level of residual activity, prevent pain and bedsores, and improve well-being.
Rehabilitation of Movement Disorders 2016 83-95
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Balance training should be functional, i.e., people should practice functions in the performance of daily tasks that
require balance and proper posture.
In addition to balance and coordination exercises, muscle strength and stretching exercises should be performed in
every position
Promote stability by using different positions and while progressing from one position to another
Keep the best posture for as long as the patient can
Rehabilitation of Movement Disorders 2016 83-95
A home practice program should incorporate other physical activities such as sport activities to train
components of basic skills in patients with ataxia.
Exercises should be practiced consciously at first, and in later stages should be followed by automatic exercise
activities
Strength training should use body weight exercises
As patients have to maintain an unbalanced position to train balance reactions, these exercises should be performed safely and progress depending on their
symptoms
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“Disturbances in the sensory input to the cerebellum” Tests of proprioception- Joint sense, passivemovement “The corrective effects of the Visual system”Classical Sensory Ataxic GaitRomberg’s sign Loss of tendon reflexes Features of Peripheral neuropathy
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Orthotics in Patients with dystonia meets the objective of correcting the position of the hand in order to facilitate the function and prevent deformity.
Because the movement is generated for a functional objective based on a pattern or muscle string, when manufacturing the orthotic the therapist should consider the position and angulations of the wrist in order to facilitate the initiation of the chain movement (neutral or minimal flexion).
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Chairs should provide sufficient stability and symmetry in the pelvis.
The seat model depends on how much axial support needed. They provide containment of the pelvis and trunk, facilitating
the use of upper extremities in different planes, without the need for proximal fixation in the extremities.
For wheelchair and sitting it is a priority to give abduction and flexion at an angle less than 90 degrees to the pelvis to make sure the center of gravity is back and avoid the extensor pattern
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Recent Advances
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Conventional gait training does not restore a normal gait pattern in the majority of stroke patients
Robotic devices are increasingly accepted among many researchers and clinicians and are being used in rehabilitation of physical impairments in both the upper and lower limbs
Belda-Lois et al. Journal of NeuroEngineering and Rehabilitation 2011, 8:66
Advantages
Safe, intensive and task-oriented
rehabilitation
Precisely controllable assistance or
resistance during
movements
Good repeatability
Objective and quantifiable measures of
subject performance
Increased training
motivation through the use
of interactive (bio)feedback.
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(a) The GyroGlove™ is worn to reduce hand tremor when the patient requires accurate hand movements (b) LiftLabs™ tremor cancelling spoon, which
improves accuracy by opposing tremor caused by disease
Greydon Gilmore and Mandar Jog. Future Perspectives: Assessment Tools and Rehabilitation in the New Age. Movement Disorders Rehabilitation, DOI 10.1007/978-3-319-46062-8_10
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Brain-Computer Interface (BCI) systems record, decode, and translate some measurable neurophysiological signal into an effector action or behavior
BCIs establish a direct link between a brain and a computer without any use of peripheral nerves or muscles
The enable enabling communication and control without any motor output by the user
Belda-Lois et al. Journal of NeuroEngineering and Rehabilitation 2011, 8:66
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Functional near infrared spectroscopy (fNIRS) is a noninvasive psycho-physiological technique
It utilizes light in the near infrared range (700 to 1000 nm) to determine cerebral oxygenation, blood flow, and metabolic status of localized regions of the brain
fNIRS uses multiple pairs or channels of light sources and light detectors operating at two or more discrete wavelengths.
Belda-Lois et al. Journal of NeuroEngineering and Rehabilitation 2011, 8:66
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ADVANTAGES
Greater consistency of therapy
Home use
Never tiring out
Highly motivating
Optimized patient support
Precise measurements & assessments
Labor and therapy costs saving
ISSUES
Less flexible than therapist
Risk of obsolescence
Costly
Space consuming
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Belda-Lois et al. Journal of NeuroEngineering and Rehabilitation 2011, 8:66
It is reasonable to expect a better insight in the understanding of the rehabilitative process if top-down approaches are considered.
Regarding neurophysiological and motor learning Techniques, there is insufficient evidence to state that one approach is more effective than the other
There is moderate evidence of improvement in walking and motor recovery using robotic devices including systems for BWS when compared to conventional therapy
The combination of different rehabilitation strategies seems to be more effective than over-ground training alone
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Belda-Lois et al. Journal of NeuroEngineering and Rehabilitation 2011, 8:66
Rehabilitation in Movement disorder is challenging Though there are definite evidence available in diseases like
PD and Ataxia, we still searching for ideal plan for Chorea and Dystonia
Psychological support in above is crtitical besides medical therapy
Rehabilitation need to continue even post surgery in Dystonia MDT could make a difference in QOL with these syndrome
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