Stroke Rehabilitation
Wael Alasaq PT, PhD.
Kuwait University
Physical Therapy Dep.
Dr. Wael Alasaq Aug. 2005
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Theory
The importance of theories
Motor control
Motor learning
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Bases for rehabilitation
What is a theory?
• An abstract idea that provide an answer or
a description about a phenomenon.
• Motor control theories are abstract ideas
about the nature and cause of movement.
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• Why do we use theories? What is the
importance theories?
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What is motor control theory?
• Motor control: is the study of the nature
and cause of movement.
• Theory of motor control: is a group of
abstract ideas about the nature and cause
of movement. Theories are often, but not
always, based on models of brain function.
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Why there are many theories?
• For explaining
• Answering what is messing from others
• New discoveries
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How theories affect rehabilitation?
In the past:
• CNS is thought of as rigid and unalterable.
• Regeneration & reorganization was not
possible within the CNS.
• Treatment focus was on the use of what
ever movement available (leading to
compensation)
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How theories affect rehabilitation?
Currently:
• More recent research in the field of
neuroscience show that adult CNS has
great plasticity and an incredible capacity
of reorganization.
• Thus ttt focus is on recovery ( achieving
task goals using effective & efficient
means, but not necessarily those used
premorbidly)
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Theories of motor control & motor
learning
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Reflex theory
Hierarchical theory
Motor programming Theory
Systems theory
Dynamical action theory
Parallel distributed processing theory
Task-Oriented theory
Ecological theory
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Motor learning
• Motor learning: the study of the acquisition
& modification of movement.
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Motor learning theories
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Adam’s Closed-Loop theory
Schmidt’s Schema theory
Fitts & Posner: Stages of motor learning
Newell’s theory of learning as exploration
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Brain reorganization & Functional
recovery
• To date there is no medical intervention to
reduce the extent of neural damage
following stroke.
• How can we then improve functional
outcome?
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Brain reorganization & Functional
recovery
Cont.
• Neural system is being remodeled
throughout life & after injury by experience
& in response to activity and behavior
(Jenkins et al. 1990, Johansson 2000, Nudo et al. 2001)
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Brain reorganization & Functional
recovery Cont.
• Hebb (over half a century ago) suggested
that neural cortical connections can be
remodeled by our experience.
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Brain reorganization & Functional
recovery
Cont.
• Foundation for functional plasticity:
– There is an extensive overlapping of muscle
representation within the motor map, with
individual muscle & joint representations rerepresented within the motor map
– Individual corticospinal neurons diverging to
multiple motoneuron pools.
– Horizontal fibers interconnecting distributed
representations.
(Nudo et al. 2001)
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Brain reorganization & Functional
recovery Cont.
• Changes in the nervous system may occur
according to the patterns of use.
(Pascual-Leone & Torrres 1993)
• These studies stress the changes associated
with active, repetitive training & practice, & by
the continued practice of the activity.
• Restriction of activity or disuse associated with
immobilization or amputation causes alterations
in the cortical representation (reduction).
(Leipert et el. 1995)
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Brain reorganization & Functional
recovery Cont.
• This suggests that the neural system is
flexible and adaptive, and respond to
many factors, including patterns of use.
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Brain reorganization & Functional
recovery Cont.
• The current technology of imaging
systems have confirmed that:
– the cerebral cortex is functionally and
structurally dynamic
– neural reorganization occurs in human cortex
after stroke
– Altered neural activity patterns and molecular
events influence this functional reorganization
(Johansson 2000)
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Brain reorganization & Functional
recovery Cont.
Two types of processes underlying functional
recovery following stroke:
1. Reorganization of affected motor regions
– Changes in membrane excitability
– Growth of new connections or unmaking of preexisting connections
– Removal of inhibition and activity-dependent synaptic
changes
– Plastic changes in subcortical regions.
2. Changes in the unaffected hemisphere.
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Brain reorganization &
Functional recovery Cont.
• Importance of active use of the limb for the
survival of the undamaged neuron
adjacent to those damaged by cortical
injury & that retention of the spared hand
area & recovery of function after cortical
injury might depend upon repetitive
training and skilled use of the hand.
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Brain reorganization & Functional
recovery Cont.
• There is relationship between PT intervention
and reorganization of the cerebral cortex.
Lieper et al. (2000)
• Usually the recovery of function starts 3-4
weeks. During these 3-4 Wks there is resolution
of edema, absorption of necrotic tissue debris
and the opening of collateral channels for
circulation to the lesioned area.
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The Rehabilitation Environment
The reorganization & functional recovery
from brain lesion are dependent on 3
factors:
1. Use
2. Activity
3. Environment in which the
rehabilitation is curried out.
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The Rehabilitation Environment
cont.
The rehabilitation environment is made up
of:
1. The physical built environment (physical
setting)
2. The method used to deliver rehabilitation
3. The staff, their knowledge, skills & attitudes.
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Time spent on Activity
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Structuring a Practice
Environment
The goals of PT intervention are to provide:
1. Opportunities for an individual to regain optimal
skilled performance of functional actions
2. to increase level of strengths
3. to increase level of endurance
4. to increase level of physical fitness
• Emphasis should be placed on the time spent on
practice as well as the type of practice
(Small & Solodkin 1998)
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Delivery of Physiotherapy
• Independent practice
• Group practice
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Group exercise & training
What kind of benefits it has on therapist,
patient and training program?
What are the factors that may influence
the amount of independence practice?
– Patient's level of disability
– Willingness by the pt
– Understandability of the exercise to be curried
out
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Group exercise & training Cont.
How to encourage understandability?
– Brief explanation with demonstration
– List of diagrams
– Workbook
– Feedback (verbal, graphs, number, speed
etc)
– Personalized according to pt's needs &
situation
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Group exercise & training Cont.
Why do we need to increase time spent in
exercise?
– Improve physiological responses, such as
endurance, strength, and fitness.
– Improve functional motor performance (more
repetitions leading to mastering the skill)
– Achieve goals of the treatment
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Optimizing skill
What is a skill?
A skill is:
• 1- "Any activity that has become better
organized & more effective as a result of
practice”
(Annett 1971)
• 2- "The ability to consistently attain a goal
with some economy of effort“
(Gentile 1987)
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Optimizing skill
Cont.
How to optimize a skill?
• Braking the movement down into its
segmental constituents
• Task oriented training to gain the
necessary control
• Through training and repetition muscle
motor learning is taking place and more
strength is gained.
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Optimizing skill
Cont.
Stages of learning skills:
– Cognitive stage ( getting the idea of the
movement)
– Intermediate or associative stage (preparing
for adaptation of the movement pattern)
– Final or autonomous stage (owning it,
mastering it)
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Optimizing a skill
Cont.
Factors for optimizing a skill:
a- focusing attention
b- Provision of feedback
c- Transfer of learning
d- Practice
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A- Focusing attention
Learning of motor skills involves:
• Identifying what is to be learned.
• Understanding the ways for goal
accomplish
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Identifying what is to be learned
• Two methods for directing the focus of
attention
1.Demonstration (live & recorded) (Fig 1.4)
2.Verbal instruction
• Should be brief
• Simple (no too much details, U will kill him)
• In a language that is understood by the patient (Fig
1.5)
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Understanding the ways for goal
accomplish
Setting goals, should be:
• Meaningful
• Reasonably challenging but yet attainable
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b- Feedback
• Very important for skill acquisition about
performance.
• There are two types of feedback, intrinsic and
extrinsic (augmented)
• Intrinsic, is the sensory feedback (visual,
proprioceptive, tactile)
• Extrinsic (Augmented) feedback provide
knowledge of the result of action (KR) and
knowledge of the performance (KP), such as
therapist or instrument (e.g. EMG)
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C- Transfer of learning
• Transfer training (learning) from practice
environment (rehabilitation setting) to
other environments.
• A closed motor skill vs. Open motor skill
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d- Practice
• Optimizing performance through repetition
in order to increase strength, skill
development as well as training for muscle
coordination.
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d- Practice
Cont.
Discuss how would you keep patients
motivated during practice, as it involves
repetition of actions?
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d- Practice
Cont.
Remember:
Patients need to practice in different
contexts in order to develop flexibility to
apply motor tasks into different
environment..
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