Thalamic Stroke

[neuron]

My client has been diagnosed with thalamic stroke 6 months having Reflex Sympathetic Dystrophy (RSD) and severe sensory impairement. Besides having good motivation and determination towards the improvement patient has the ignorance of his one side of the body due to sensory impairement. Anyone has any idea how long will it take to recover the sensation? or will it recover?, any specialised PT approach to recover the sensation. Kindly advise me.
Advance Thank you
Neuron :thumbs_up

[bernard]

Neuron,

which side is the neglected one?

Neglect is a source of failure of PT. Rajil may respond more precisely to this question.

[neuron]

Hi Bernard,
Thanks for your reply, client has been recieving intensive rehab program since his stroke. his left side is the sensory impairment. Client is aware of that he has sensory impairement and trying to maximse his usage on his loeft hand side perhaps, his Left upperbody, lower body pain(Thalamic Pain?, RSD?) which causes him to restrict his activity on the affected side.

Thanks

[rajulvasa]

Hi Bernard,
client has been recieving intensive rehab program since his stroke. his left side is the sensory impairment. Client is aware of that he has sensory impairement and trying to maximse his usage on his loeft hand side perhaps, his Left upperbody, lower body pain(Thalamic Pain?, RSD?) which causes him to restrict his activity on the affected side.

Thanks
Hi Neuron
U have not mentioned his neurological status, does he only complain of pain in the entire body? does he recognise what is given in his hand with eyes closed? If he does not, please do not encourage any kind of rehab programme that involves external sensory inflow using objects with different texture, different sizes, different temparature, different densities etc.Any type of external sensation will surely do one thing, that is to garble the information as his thalamo cortical connections are no longer the same.
Remember that for majority of the ambulatory activities, sensations must be recognised only at spinal & subcortical level which is normal in his case & cortical sensations or perception u need from the touch is mandatory if UR patient is a cook or a masson or a carpenter etc and this cortical sensations are possible only if u can exploit CNS plasticity rightly.

The best way to restore the sensation is ask him to use his own right hand to move all over his left side of the body,(not the hand of the therapist or a family member) this is his rehab programme to be repeated as many times as possible to encourage thalamo-thalamic connections (CNS PLASTICITY) to take over. This takes long but it does happen specially when the patient is highly motivated & for sure his own touch if repeated, will free him from the pain very shortly.
Do not let him expose his left side to the strong blast of the wind & strong differences of temparature.

What about motor control? does he have thalamic dystonia?
U need to tell me in detail his present state
How do u conclude he has RSD?

Feel Free for any type of Q that arise in UR mind, I like to be questioned!
Any somasimpler may also feel free to ask!

[Arun]

Hi Rajul,
I suppose you are referring to Constraint-Induced Movement Therapy (CI-therapy) here which has obviously been proven to decrease 'learned nonuse' through somatosensory input and thus increasing the extent of cortical representation of the affected area. But I couldn't understand how will it promote the thalamo-thalamic connections? Is there such a thing like that or were u referring to the thalamo-cortical extensions here?

Thanks

[bernard]

Rajul,
I think it is the left side that is impaired (Right brain)?

Arun,
Rajul is not using a conventional CI in my view, but developed her technique based upon observations and CNS plasticity.

[rajulvasa]

Rajul,
I think it is the left side that is impaired (Right brain)?

Precisely Bernard.
His left hand is affected & therefore to use the normal sensation of the RIGHT HAND to move all over the left side of the body. (To completely bypass the garbled information from right thalamus to right cortex) & to establish connections between Right & left thalamus to reach to the cortex. CNS plasticity will help establish connections between two thalamus, ofcourse with time BUT bypassing the sensory information using good hand sensation relieves the thalamic pain very shortly.
Arun,
Rajul is not using a conventional CI in my view, but developed her technique based upon observations and CNS plasticity.

[rajulvasa]

Hi Rajul,
I suppose you are referring to Constraint-Induced Movement Therapy (CI-therapy) here which has obviously been proven to decrease 'learned nonuse' through somatosensory input and thus increasing the extent of cortical representation of the affected area. But I couldn't understand how will it promote the thalamo-thalamic connections? Is there such a thing like that or were u referring to the thalamo-cortical extensions here?

Thanks
Please do not jump to conclusion.
Do not use terminology like 'learned nonuse' without thinking as here I meant to use good hand & not affected hand. Mind u not for voluntary movements BUT purely to have contact of the left body with right hand.
Right thalamus to be bypassed using good right hand & left thalamus.
Use left thalamo cortical connections to relieve pain & to make sure that right thalamo cortical connections are not encouraged to interconnect & are definately not used & with time are expected to get dystrophied

[bernard]

Sorry Rajul,

I need to read more carefully the posts. :embarasse

[Arun]

Arun,
Rajul is not using a conventional CI in my view, but developed her technique based upon observations and CNS plasticity.

Bernard,
Isn't CIT itself have its background based on neuroplasticity theories?



Please do not jump to conclusion.
Do not use terminology like 'learned nonuse' without thinking as here I meant to use good hand & not affected hand. Mind u not for voluntary movements BUT purely to have contact of the left body with right hand.
Right thalamus to be bypassed using good right hand & left thalamus.
Use left thalamo cortical connections to relieve pain & to make sure that right thalamo cortical connections are not encouraged to interconnect & are definately not used & with time are expected to get dystrophied


Rajul,
That was not a conclusion by the way. Sorry that I overlooked some of your points here.
But I still have doubts as how could this bye passed sensory information help to reduce this patient's sensory symptoms on the left side? Thru contralateral thalamo-cortical extensions? If so how is he percieving the sensory disturbances that he has on the left side now? Isn't the parieto-insular cortex which recieves these ascending relays from the thalami responsible for recognition of the same?
I'm a bit confused with your concept.

[bernard]

Arun,
Isn't CIT itself have its background based on neuroplasticity theories?

Yes, but CIT is not really based upon observations.

[rajulvasa]

Bernard,
Isn't CIT itself have its background based on neuroplasticity theories?


Rajul,
That was not a conclusion by the way. Sorry that I overlooked some of your points here.

Thanks Arun u did not conclude.
But overlooking & going public on the forum is equally dangerous as many people who view this can be mislead.

[Arun]

Arun,


Yes, but CIT is not really based upon observations.

Yes Bernard


But overlooking & going public on the forum is equally dangerous as many people who view this can be mislead.
Forums are meant to go public, interact and get responses. And not supposedly used as a blind reference sources. Doubts should always be be discussed out. emperical assumptions be validated. I would be more grateful if you could answer to my queries here.

Feel Free for any type of Q that arise in UR mind, I like to be questioned!
Any somasimpler may also feel free to ask!
I just had mine.


Thanks

[neuron]

Hi Neuron
U have not mentioned his neurological status, does he only complain of pain in the entire body? does he recognise what is given in his hand with eyes closed?
Hi Rajul,
1. sensory impairment- hot, cold, deep sensation affected.
2. Not able to recognize the object with eyes closed
3. Co-ordination affected
4. JPS affected
5. Pain - his pain at his left shoulder with any movement- no lower body pain
6. RSD- Ther's no medical evidence of RSD such as neurologist suggestion- clinical features suggests me to suspect RSD - Profused sweating,shoulder, wrist & finger pain, gentle stretching in wrist and fingers causes pain
7. Patient cannot tolerate Cold exposure - c/o pain

[rajulvasa]

Bernard,
Isn't CIT itself have its background based on neuroplasticity theories?

But I still have doubts as how could this bye passed sensory information help to reduce this patient's sensory symptoms on the left side? Thru contralateral thalamo-cortical extensions?

Yes Arun u r right there. This connections are normal & not garbled.

[neuron]

What about motor control? does he have thalamic dystonia?
Hi rajul,

I would say his muscle strength 4-/5, he's able to do movements but his pain is the limiting factor
No he's not having signs of dystonia, iam keeping close vigil on dystonia?.

Does all thalamic stroke patients presents with dystonia?

[neuron]

can someone give me some links where i can get more information about CIT?

[bernard]

http://www.stroke-info.com/special_presentations/cimt/

[rajulvasa]

Bernard,
Isn't CIT itself have its background based on neuroplasticity theories?




Rajul,
Isn't the parieto-insular cortex which recieves these ascending relays from the thalami responsible for recognition of the same?
I'm a bit confused with your concept.

Arun U R right hier, It is this ascending thalamo-cortical connections on the right side of the brain that is giving pain perception & therefore they must be abandoned completely by strictly restricting any unneccesssary inflow from therapeutics like passive stretching of wrist finger, touch of the therapist or any body else or any use of objects for sensory rehabilitation.

I will love to solve ur queries, my problem was not ur asking me any Question but comparing with something which is not relevant with my answer to NEURON.

[rajulvasa]

What about motor control? does he have thalamic dystonia?
Hi rajul,

I would say his muscle strength 4-/5, he's able to do movements but his pain is the limiting factor
No he's not having signs of dystonia, iam keeping close vigil on dystonia?.

Does all thalamic stroke patients presents with dystonia?

UR patient does not have dystonia at present & that is very good.

I believe that relieving the pain is the utmost priority & can be done very easily.
Pain in the shoulder is the trace of the element of dystonia, if u will observe he will have bad posture of the shoulder joint & will get worst with any attempt of voluntary movement & attempt for co ordination or passive mobilization.

let me alert u that if u will try
(a) sensory rehabilitation
(b) work on his motor co-ordination when he does not have joint position sense
(c) Try forced use of the left hand
(d) Give passive stretching
he will certainly develop the Dystonia.

[Arun]

Rajul,
Thanks for your replies. Started making sense now. How would you handle the motor affections? Is it equally effective in patients with predominant motor affection? If yes how do you think its working?

Thanks Again

[neuron]

UR patient does not have dystonia at present & that is very good.

I believe that relieving the pain is the utmost priority & can be done very easily.
Pain in the shoulder is the trace of the element of dystonia, if u will observe he will have bad posture of the shoulder joint & will get worst with any attempt of voluntary movement & attempt for co ordination or passive mobilization.

let me alert u that if u will try
(a) sensory rehabilitation
(b) work on his motor co-ordination when he does not have joint position sense
(c) Try forced use of the left hand
(d) Give passive stretching
he will certainly develop the Dystonia.
Hi rajul,
Thank you for your information . let me ask you agin how do we solve this pain ? any different approach than the conventional Therapeutic approach? Does Russian stimulation Helps?What other therapy programme i can approach with this patient?

[rajulvasa]

Hi rajul,
Thank you for your information . let me ask you agin how do we solve this pain ? any different approach than the conventional Therapeutic approach? Does Russian stimulation Helps?What other therapy programme i can approach with this patient?

Neuron,
I hope u have got the clue how to solve the pain problem or u need to look into my previous post more carefully.
Conventional therapeutic approach for such a patient will guarantee failure & may be disaster.

does Russian stimulation Help? Any external stimulation will certainly promote right thalamo cortical connections & ensure the pain.

Other therapy programmes that u are looking for, I am afraid to say that, if r based on sensory stimulation , motor coordination, passive mobilization, stretching, cortical gait training,forced use etc will get the patient more close to the worsening of symptoms & rigidity in muscles which r already having good power.

[neuron]

Other therapy programmes that u are looking for, I am afraid to say that, if r based on sensory stimulation , motor coordination, passive mobilization, stretching, cortical gait training,forced use etc will get the patient more close to the worsening of symptoms & rigidity in muscles which r already having good power

Hi rajul,
well i agree with you for the pain approach. But now my querie is if we don't use the left side (bad hand) does it leads to Neglect?, if we delay ambulation or wait untill the recovery of sensation do you think it's too late in terms of the gait training and balance retraining.

[rajulvasa]

Other therapy programmes that u are looking for, I am afraid to say that, if r based on sensory stimulation , motor coordination, passive mobilization, stretching, cortical gait training,forced use etc will get the patient more close to the worsening of symptoms & rigidity in muscles which r already having good power

Hi rajul,
well i agree with you for the pain approach. But now my querie is if we don't use the left side (bad hand) does it leads to Neglect?, if we delay ambulation or wait untill the recovery of sensation do you think it's too late in terms of the gait training and balance retraining.

Hi Neuron
U sound a very commited physio willing to help ur patient with as much motivation as ur patient who is also equally motivated.
I will try my best to guide u on this forum. Thanks to Bernard.

Let us come to using the left hand: Do u think u can think of using this hand in any other fashion? specially when he has farely good & incoordinated motor control? I hope u can give me some option by well describing ur thought process because ur imagination right or wrong does not matter will surely motivate me to invest my time in u.

U surely do not have to wait for sensation to recover for ambulation.
Balance retraining is not only mandatory but takes a priority.
BUT what is important to achieve both of this is that u plan all ur therapeutics that are far from constantly instructing the patient that will make auditory & visual cortex highly active.

Plan for subcortical & spinal actions.
U know locomotion is a very rhythmical subcortical & spinal affair.
Cortical training for a subcortical affair itself is the biggest mistake, which i am sure u will not make.

Any confusion on visual guidance part feel free to ask.

[rajulvasa]

Rajul,
Thanks for your replies. Started making sense now. How would you handle the motor affections? Is it equally effective in patients with predominant motor affection? If yes how do you think its working?

Thanks Again
Is it equally effective? in patients with predominant motor affection?
Hi Arun
I need to know "what" is equally effective?

[neuron]

Right thalamus to be bypassed using good right hand & left thalamus.
Use left thalamo cortical connections to relieve pain
Hi rajul,
Thank you for your suggestions i think it helps me well do you have any proven article for the above mentioned. if, can please provide the link
thank you

[neuron]

Any external stimulation will certainly promote right thalamo cortical connections & ensure the pain

Hi rajul,
also this do you have any evidence supporting your concept?

thank you

[bernard]

Neuron,

Evidences are certainly very important but experience too. And Experience is the tomorrow's evidences.

[rajulvasa]

Neuron,

Evidences are certainly very important but experience too. And Experience is the tomorrow's evidences.
Thank you very much Bernard for helping

Dear Neuron,
Evidences will come in time as my research work in Nancy progresses with the French Neurophysiologist who got all evidences in practical terms on their patients in clinical practice with vasa concept.

Also your own experience " it helps me well " will lead you to search & research & search again in your own thinking which is the first essential for any kind of scientific research in a laboratory.

Keep your eyes & ears open & do not get biased with the research work of our Predecessors as in this present times we must contribute to the research so that our future generation can say that their predecessors that is "WE" of today also contributed our share to research & "WE" hope the next generation continues without getting biased by what we are saying today & continue into the future research to benifit the mankind.