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Therefore, motor recovery that occurs during rehabilitation relies on two general processes that can be achieved through several different mechanisms Box 5. Animal and human studies demonstrate that motor rehabilitation after stroke causes a restoration and reorganization of function within motor cortex Table 5.

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Function within residual cortical tissue that was compromised after damage is restored with rehabilitation. Rehabilitation can drive residual neural tissue to reorganize in order to compensate for lost function. Table 5. Conclusions: understanding plasticity can enhance rehabilitation 45 Box 5. Physiotherapists need to identify which interventions are most effective at restoring movement and inducing plasticity following brain damage. Box 5. However, by identifying the basic principles that govern experience-dependent plasticity, new insights into how therapy should be administered may be gained.

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Use it or lose it 2. Use it and improve it 3. Repetition matters 5. Salience matters 8. Age matters 9. Transference matters Neural plasticity is a complex cascade of molecular, cellular, structural and physiological events. There may be time windows in which it is particularly effective in directing the lesion-induced reactive plasticity. Time matters Conclusions: understanding plasticity can enhance rehabilitation 47 48 Neural plasticity in motor learning and motor recovery 5 adjuvant therapies such as cortical stimulation manipulations that augment neural plasticity also enhance motor recovery see Table 5.

Journal of Applied Physiology 6 — Allred RP, Jones TA Unilateral ischemic sensorimotor cortical damage in female rats: forelimb behavioral effects and dendritic structural plasticity in the contralateral homotopic cortex. Experimental Neurology 2 — Barbay S, Plautz EJ, Friel KM et al Behavioural and neurophysiological effects of delayed training following a small ischemic infarct in primary motor cortex of squirrel monkeys.

Experimental Brain Research 1 — Journal of Neuroscience 24 5 — Boyd L, Winstein C Explicit information interferes with implicit motor learning of both continuous and discrete movement tasks after stroke. Journal of Neurologic Physical Therapy 30 2 — Journal of Neurophysiology 91 5 — Butterworth-Heinemann, London, Chapter 2.

Journal of Neuroscience 19 22 — Journal of Neuroscience 25 44 — Archives of Physical and Medical Rehabilitation 87 2 — Gilmore PE, Spaulding SJ Motor control and motor learning: implications for treatment in individuals post stroke. Physical and Occupational Therapy in Geriatrics 20 1 :1— Journal of Neurophysiology — Kleim JA, Bruneau R, VandenBerg P et al Motor cortex stimulation enhances motor recovery and reduces peri-infarct dysfunction following ischemic insult.

Neurological Physiotherapy Pocketbook

Neurology Research 25 8 — Journal of Neuroscience 24 3 — Koski L, Mernar TJ, Dobkin BH Immediate and long-term changes in corticomotor output in response to rehabilitation: correlation with functional improvements in chronic stroke. Neurorehabilitation and Neurological Repair 18 4 — Journal of Neurologic Physical Therapy — Annals of Neurology 58 6 — Cerebral Cortex 16 8 — Journal of Comparative Neurology 4 — Neuroscientist 11 5 : — Journal of Neural Transmission 1 :3— Nudo RJ Adaptive plasticity in motor cortex: implications for rehabilitation after brain injury.

Journal of Rehabilitation Medicine 41 7 :7— Journal of Neuroscience 16 2 — Science — Experimental Brain Research 2 — Neurocase 12 1 — Rosenkranz K, Nitsche MA, Tergau F et al Diminution of training-induced transient motor cortex plasticity by weak transcranial direct current stimulation in the human. Neuroscience Letters 1 — Stroke 37 1 — Champaign IL, Human Kinetics. Journal of Neurophysiology 92 1 — Taub E, Uswatte G, Morris DM Improved motor recovery after stroke and massive cortical reorganization following constraint-induced movement therapy.

Tyc F, Boyadjian A, Devanne H Motor cortex plasticity induced by extensive training revealed by transcranial magnetic stimulation in human. European Journal of Neuroscience 21 1 — Voorhies AC, Jones TA The behavioral and dendritic growth effects of focal sensorimotor cortical damage depend on the method of lesion induction.

Behavioural Brain Research 2 — Brain 3 — Winstein CJ, Rose DK, Tan SM et al A randomized controlled comparison of upper extremity rehabilitation strategies in acute stroke: a pilot study of immediate and long-term outcomes. Archives of Physical and Medical Rehabilitation 85 4 : — Wittenberg GF, Chen R, Ishii K et al Constraint-induced therapy in stroke: magnetic-stimulation motor maps and cerebral activation.

Neurorehabilitation and Neural Repair 17 1 — Journal of the American Medical Association 17 — Neuroimage 27 4 — Zhao CS, Puurunen K, Schallert T et al Effect of cholinergic medication, before and after focal photothrombotic ischemic cortical injury, on histological and functional outcome in aged and young adult rats.

Behavioural Brain Research 1 — This chapter outlines background information on these neurological conditions, summarized from Stokes A detailed overview of medical management can be found in Warlow Aspects of physical management are dealt with elsewhere in this pocketbook: physiotherapy management including assessment, treatment, maintenance and prevention of complications of the most commonly encountered conditions is covered in Chapter 10; neurological investigations and common drug treatments are presented in the Appendices; the wider impact of neurological disability, including carers, is considered in Chapters 2 and 3; transfer of care and long-term management are addressed in Chapter Further details for neurological paediatrics can be found in Aicardi and Belderbos STROKE Stroke is the third most common cause of death worldwide and a major cause of disability; age standardized incidence for people aged 55 years or more ranges from 4.

The diagnosis of stroke is reliant on a comprehensive neurological examination, supported by imaging to exclude conditions that mimic stroke. Stroke should be considered as a medical emergency so that appropriate treatment can be started.

Pocketbook of Neurological Physiotherapy (Physiotherapy Pocketbooks)

Three interventions which help prevent death or dependency are: 1 stroke unit care regardless of age or stroke type, and for ischaemic stroke; 2 aspirin; 3 thrombolysis with alteplase Dewey et al Key features of stroke are summarized in Table 6. The most frequent causes of ABI are: trauma, infections, e.

This chapter will focus on the management of traumatic brain injury TBI , although the general principles can be adapted to ABI from other causes. Sporting accidents, transport accidents, assaults and falls are the primary causes of TBI. Incidence ranges from to new cases of TBI Effects of stroke are determined by the areas of brain damage, irrespective of the cause.

Left hemisphere lesion: normally associated with severe communication problems. Right hemisphere lesions: normally associated with perceptual disturbances. Also termed cardiovascular accident CVA. Transient ischaemic attack TIA : a stroke-like syndrome in which recovery is complete within 24 hours. Key features are summed up in Table 6. Table 6. Injury may be closed intact skull or penetrating risk of infection.

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Severity of injury ranges from mild concussion to very severe injury resulting in death. Pathology Primary damage: direct impact on the skull, penetration through the skull into the brain, collision between the brain and the inside of the skull; all may cause widespread shearing and tearing of brain tissue such as axons. Secondary damage: oedema, haematoma, and infection may result in displacement and compression of brain tissue with occlusion of major arteries. Symptoms Impairments of physical function are wide ranging e. Impairments of behaviour and emotional functioning e.

Increased intracranial pressure ICP may lead to decreased cerebral perfusion and ischaemia. Associated injuries: a high percentage of patients have associated injuries e. Time course Varies according to severity of injury. Post traumatic amnesia PTA : period from injury until return of day to day memory.

Incidence is about 3.

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Physiotherapists tend to see people who are more seriously affected, but it is important to realize that many people maintain their preferred life style remaining stable in between relapses. Breaking the news of a diagnosis of MS is always a stressful event for patients and their carers. NICE recommends that an individual should be informed of the potential diagnosis of MS by a doctor with specialist knowledge about MS as soon as it is considered reasonably likely.

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Key features are summarized in Table 6. SCI is an example of an upper motor neurone lesion leading to varied amounts of spasticity and weakness. Since the spinal cord is shorter than the vertebral column, only extending to L1 or L2 level, lower vertebral injuries normally at a cut off level of T12 will not involve damage to the cord but damage to the nerve roots, a peripheral nerve injury. A chronic progressive demyelinating disease, characterized by focal disturbance of function, with a relapsing and remitting course periods of attacks and remission , usually presenting between the ages of 20—40 years and occurring more commonly in females than males.

Loss of insulation causes interruption of normal nerve conduction travel of impulses along a nerve. Early symptoms may be vague: fatigue, lack of energy, aching limbs, sensory disturbances. Other symptoms, some of which may be exacerbated by temperature changes, include: Sensory, e. Time course Individual variation — pattern cannot be predicted, but remember does not always lead to severe disability and loss of mobility.

Upper limb function is spared. Pathology Primary: loss of axons due to contusion or tearing damage of the white matter. Complete: Paralysis and loss of sensation below the level of lesion. Disruption to respiration: Injuries from C1 to C3 level paralyse all muscles of respiration including the diaphragm.

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Paralysis of some respiratory muscles is a feature of any lesion above T6 with reduced vital capacity and ineffective cough due to loss of abdominal muscles. Cervical lesions above the C4 level of injury will require ventilation. Paralytic ileus and gastric distension can further restrict movement of the diaphragm compromising breathing. Sympathetic disruption occurs in cervical and upper thoracic lesions with impairment of tachycardia response, and lowering of blood pressure.

Disruption of postural control balance in any lesion above T A new postural sense is developed by visual control. In lesions above T6, postural control is also achieved through muscles with high innervation and low distal attachment e. Denervated skin is at risk from pressure damage within 20—30 minutes of injury.

Spinal cord injury 59 Table 6. Incontinence due to disruption of the neural control of the bladder means that the patient requires catheterization. Disruption to neural control of the bowel requires retraining to ensure bowel evacuation; constipation can be an issue. Pain associated with neck and back pain and other injuries, as well as from overuse at a later stage. Sexual dysfunction: fertility is usually maintained in women, but problematic in men.

Automatic erections occur in complete lesions above the conus, but there is no sensation during intercourse Bromley Osteoporosis loss of bone mass may lead to fractures. Other syndromes Symptoms are related the anatomical areas of the cord affected. Anterior cord syndrome — complete motor loss caudal to the lesion, and loss of pain and temperature sensation. Brown-Sequard syndrome — ipsilateral paralysis with contralateral loss of temperature and pain sensation.