"Big picture" of brain changes may be crucial to recovery from stroke injury

[Diane]

This is for Rajul,
Thought you might be interested in this:
http://mednews.wustl.edu/news/page/normal/5963.html?emailID=6884

[nari]

While waiting for Rajul's reply, I'll have a bit of a say - for years some neurologists have talked about the 'watershed' effect of a stroke, particularly if the event occurs on the (R) side, which is traditionally associated with spatial neglect and cognitive changes. But often other odd symptons/signs appeared which were not concomitant with the injury site; so they would describe the watershed effect as a reason for these apparent anomalies. They referred to associations and connections as being the reason, depending on the severity of the event and the time lapse between the event and admission to hospital.

It's good to see it validated.


Nari

[rajulvasa]

Thank you Diane
It is definately interesting to understand effect of a lesion in far off regions.
Effects could be negative as well as positive as CORBETTA describes it
"brain regions can only perform their functions properly through connections with other brain regions. Alter the function of one brain region through injury, the theory proposes, and the connections that usually enable normal function will lead to alterations in the function of other potentially distant brain areas"

Every CNS re-organises following the injury & this re-organisation depands a lot on how this injured CNS is handled psychologically, chemically, physically, & what kind of external , internal stimuli it is exposed to & how this CNS tries to cope up with such inflow decides the future of sensory motor output & to a great extent this sensory motor output becomes responsible for psychological emotional depression quite often treated with antidepressive drugs causing further chemical genaralised depression of the CNS & vicious circle continues.


CNS re-organisation & CNS plasticity are two constant phenomena that holds future for stroke patient if it is understood in clinical perspective by therapists & not get influenced by so called experts in diagnosing the condition i.e. Neurologists who has expert's limitation to see the unseen & those experimenting in the laboratory are unfortunately not exposed to the patient as desired, as they are not involved in the treatment of the patient like therapists who experiences the CNS as often as daily in many cases for a long period of time.

[flaviovitor]

Hello Rajul,

might you show us what kind of NEWEST treatment is being used in the Rehabilitation of the neurological patient, mainly in regards to gait?

For example, in October / 2005, we just have had a Brazilian Physiotherapy Congress, which one brought some interesting subjects like:

1) Locomotor retraining post-stroke: Revolutions in science leading to new approaches in the clinic

2) Exploring the neurophysiologic mechanisms underlying restoration of upper and lower extremity motor function after spinal cord injury


Unfortunatelly, I did not go at this congress and so, I cannot tell you all what was talked about the above themes (do you know or imagine anything about them?


Flávio.

[rajulvasa]

Hello Rajul,

might you show us what kind of NEWEST treatment is being used in the Rehabilitation of the neurological patient, mainly in regards to gait?


1) Locomotor retraining post-stroke: Revolutions in science leading to new approaches in the clinic
2) Exploring the neurophysiologic mechanisms underlying restoration of upper and lower extremity motor function after spinal cord injury


Unfortunatelly, I did not go at this congress and so, I cannot tell you all what was talked about the above themes (do you know or imagine anything about them?


Flávio.

Hi Flavio
I can tell u what is going on in the world as the "Revolutions in science leading to new approaches in the clinic" is gait training with overhead trunk support to partially support the body weight while patient is made to walk on the treadmill. Stroke as well as spinal injury patient both are made to get gait training with this high technological machines.

Functional electrical stimulation is another technological development

Gait Analysis laboratory is also used for the scientific records about gait & different parameters.

[nari]

Rajul

When I left the neuro ward after 11 years, my successor had installed one of these overhead gait-training gadgets; I don't know much about their success or failure to rehabilitate satisfactorily.

What is your opinion of their value? Or is it mostly another toy that looks impressive to relatives? (Pardon the sarcasm)

Nari

[rajulvasa]

Rajul

When I left the neuro ward after 11 years, my successor had installed one of these overhead gait-training gadgets; I don't know much about their success or failure to rehabilitate satisfactorily.

What is your opinion of their value? Or is it mostly another toy that looks impressive to relatives? (Pardon the sarcasm)

Nari

Hi Nari
Congratulations for stating "THE FACT" {is it mostly another toy that looks impressive to relatives? (Pardon the sarcasm}

U know how impressively but illusively EMG biofeedback machines were used in rehab to train muscles to reduce spasticity & also to improve hypotonic muscle! One toy for two Opp problems!


Now this new toy is used for gait training Success or failure in using these toy is so relative !
In my opinion it helps the following.

1) Companies who sale it. MONITORY BENIFIT!
2) Rehab Dept head takes pride in declaring his or her dept as most modern & update.
3) Machine can come handy to disguise therapeutic failure
4) Machine also comes handy to cover up the self guilt if, it still exists in morally responsible therapist.
5)Physios do not have to work physically as much, so backs of physios remain protected from needing physiotherapy PHYSICAL BENIFIT!
6) Helps to add on the low self esteem that some physios have in front of medical doctors. PSYCHOLOGICAL BENIFIT
7) It impresses the patient psychologically helps to add on the low self esteem. PSYCHOLOGICAL BENIFIT
8) Family does not question on the fat bills as they know high tech always costs.
9) Insurance companies do not resist paying if high tech treatments are offered (may be secret tie up between insurance company & Machine manufacturer!) could be a joke!
May be u will add more on the list of who really benefits.

I know for sure it does more damage than any good to a stroke patient

[nari]

Thanks, Rajul

I do not know much about these machines but a possible use for one is if you have a 120kg patient with a stroke and no guarantee of any assistance - though I usually had a junior PT to work with me.

Do you think it is true that 'miming' a walking/standing pattern with this machine MIGHT enhance motor cotrol? Since I left the ward, I have learned a lot more about the brain and I have my doubts.....

Nari

[rajulvasa]

Thanks, Rajul

I do not know much about these machines but a possible use for one is if you have a 120kg patient with a stroke and no guarantee of any assistance - though I usually had a junior PT to work with me.

Do you think it is true that 'miming' a walking/standing pattern with this machine MIGHT enhance motor cotrol? Since I left the ward, I have learned a lot more about the brain and I have my doubts.....

Nari
Nari your doubts are not simply doubts but a bitter truth. Miming remains a miming nothing more than that.
Man with 120 plus kilogram can be helped differently certainly not with machine where he is more likely to get passive, & still more likely to just sag instead of helping the self bit by bit.

[nari]

I guess if a guru comes along and says this is the way to go, then that has more power than no guru. I had enough trouble getting rid of the parallel bars - that caused a stir and a half. Must admit though, I never used E-Stim...resisted that one. I kept the exercise bike, though - the physios liked to use it for themselves!!

Nari

[rajulvasa]

I guess if a guru comes along and says this is the way to go, then that has more power than no guru. I had enough trouble getting rid of the parallel bars - that caused a stir and a half. Must admit though, I never used E-Stim...resisted that one. I kept the exercise bike, though - the physios liked to use it for themselves!!

Nari

I agree Nari that people need guru & people like to follow BUT sad part is that every guru is not a path finder & every guru is not able to throw light on the subject & surely many like to be a guru.
Some guru's can also mislead to masses as they have mass following & mass following does not guarantee that they have knowledge may be they only have better information with good ability of a good orator, that can easily help cover up their failure.

Congratulations for getting rid off parallel bar way back in last century (11 years before) U sure have guts & nerves to do that so long ago, unfortunately I still see them existing in developed countries. Electrical stimulation also only gives hopes to the patient without any guarantee for results.
Bike is no good for stroke patient & also must be banned.It is good for fitness for normals & for orthopedic patients.

[rajulvasa]

Interesting for neuro nuts

Volume 16, Number 23, Issue of December 1, 1996 pp. 7688-7698
Copyright ©1996 Society for Neuroscience

Primary Motor and Sensory Cortex Activation during Motor Performance and Motor Imagery: A Functional Magnetic Resonance Imaging Study

Carlo A. Porro1, Maria Pia Francescato1, Valentina Cettolo2, Mathew E. Diamond1, Patrizia Baraldi3, Chiara Zuiani2, Massimo Bazzocchi2, and Pietro E. di Prampero1

The intensity and spatial distribution of functional activation in the left precentral and postcentral gyri during actual motor performance (MP) and mental representation [motor imagery (MI)] of self-paced finger-to-thumb opposition movements of the dominant hand were investigated in fourteen right-handed volunteers by functional magnetic resonance imaging (fMRI) techniques. Significant increases in mean normalized fMRI signal intensities over values obtained during the control (visual imagery) tasks were found in a region including the anterior bank and crown of the central sulcus, the presumed site of the primary motor cortex, during both MP (mean percentage increase, 2.1%) and MI (0.8%). In the anterior portion of the precentral gyrus and the postcentral gyrus, mean functional activity levels were also increased during both conditions (MP, 1.7 and 1.2%; MI, 0.6 and 0.4%, respectively).

To locate activated foci during MI, MP, or both conditions, the time course of the signal intensities of pixels lying in the precentral or postcentral gyrus was plotted against single-step or double-step waveforms, where the steps of the waveform corresponded to different tasks. Pixels significantly (r > 0.7) activated during both MP and MI were identified in each region in the majority of subjects; percentage increases in signal intensity during MI were on average 30% as great as increases during MP. The pixels activated during both MP and MI appear to represent a large fraction of the whole population activated during MP. These results support the hypothesis that MI and MP involve overlapping neural networks in perirolandic cortical areas.

Key words: primary motor cortex; primary somatosensory cortex; motor performance; motor imagery; functional magnetic resonance imaging; brain mapping

[nari]

Rajul

Motor imagery is powerful stuff, and it is starting to be used by some PTs, but I don't know about the neurorehab scene.

Looking back over the years I spent with TBIs and strokes, there was a great deal of coercion, control and judgement made by PTs for the patients. We were the 'boss', the key to recovery. This worked for some, but I think of those who did not do well, and I have gained more knowledge since leaving the scene three years ago. I would work quite differently now, getting away from the focus on 'telling' them what to do and just concentrating on quite a different focus, allowing their brains to 'move' without directions++.

So your sentence about 'hands OFF' is quite true.

Nari

[flaviovitor]

I would work quite differently now, getting away from the focus on 'telling' them what to do and just concentrating on quite a different focus, allowing their brains to 'move' without directions++.

Hi Nari, movement is the big stuff for brain. Although movement like a robot may be considered not the ideal, this type of movement still is better than hands-on. Functional movement can be considered even better than 'robot movement'.

Motor control, some says, is not the bigger focus in Pain Rehabilitation nowadays, but, it can be, or already is, in Neurological Rehabilitation. The common point in both, is that actually what we are trying to achieve is the brain, not muscles, or not only muscles and articulations.

So, I see that robot movements rather than functional ones are still a way of rehabilitating. They don't need to be taken away.

Another point is that, however not evidenced established, imaginary movements (mirror, regognition or imagination) can be a future weapon in and for Neurological Rehabilitation. They are activating brain areas and mirror neurons too. Is that another way of creating a movement neurotag or not?


Flávio.

[rajulvasa]

Rajul

now, getting away from the focus on 'telling' them what to do and just concentrating on quite a different focus, allowing their brains to 'move' without directions++.

So your sentence about 'hands OFF' is quite true.

Nari

Hi Nari
telling the patient & giving the direction becomes dangerous when the movement is attempted & expectd with total conscious cortical efforts.

Telling & directing is only good as long as it is shown on another subject or on the therapist or on the good side of the patient's body for the patient to have an idea of what is lost & what is expected

Movements must be expected to emerge sub cortically, automatically
This is possible only if the therapist knows how to go about preparing the CNS to reflect what is expected automatically then & then :angel: it will go into the long term memory & will have carry over effect & will be energy effective OTHERWISE as we know carry over effect & long lasting results are still a far fetched dream for the present rehab gurus

[rajulvasa]

Hi Nari, movement is the big stuff for brain. Although movement like a robot may be considered not the ideal, this type of movement still is better than hands-on. Functional movement can be considered even better than 'robot movement'.

Motor control, some says, is not the bigger focus in Pain Rehabilitation nowadays, but, it can be, or already is, in Neurological Rehabilitation. The common point in both, is that actually what we are trying to achieve is the brain, not muscles, or not only muscles and articulations.

So, I see that robot movements rather than functional ones are still a way of rehabilitating. They don't need to be taken away.

Another point is that, however not evidenced established, imaginary movements (mirror, regognition or imagination) can be a future weapon in and for Neurological Rehabilitation. They are activating brain areas and mirror neurons too. Is that another way of creating a movement neurotag or not
Flávio.

Flavio
It is good that u r reading a lot BUT can u explain what do u mean by robot movement & how does it emerge? At the behest of therapist? or machines? & how permenant are they in the true sense?
So, I see that robot movements rather than functional ones are still a way of rehabilitating. They don't need to be taken away. EXPLAIN WHY?

Functional movements sometimes are achieved thro' the use of the good side or alternative compensatory movement of affected side & these r surely not economic in terms of energy effectiveness & therefore are tiring & last only in the dept in front of the therapist or guru & not carried over in the home set up.

[flaviovitor]

Rajul,

It is good that u r reading a lot BUT can u explain what do u mean by robot movement & how does it emerge?

When I say 'robot movement', I am trying to mean a movement that is performed in a flat way, and not as a 'Kabat way' (functional).


So, I see that robot movements rather than functional ones are still a way of rehabilitating. They don't need to be taken away. EXPLAIN WHY?

Because instead of doing nothing while in hospital, it is or may be better doing these 'old fashioned' exercises. Perhaps, and you have more authority than I to answer, even these kind of exercises are better than just electrical machines.

Well, Rajul, could you finish a doubt (is there another expression for this? some american, english or australian to help me? :teeth: ) of mine? Does your way of approaching stroke patients have already been published or outlined in some journal or book? Or perhaps, do you know about some approach that looks like Vasa Concept? I am asking that because I am very curious about what in fact you do within your room to your patient... the way you treat him / her.

And just like you said to Bernard, this is killing me.

Kind regards,


Flávio.


PS: what do these two book mean for you?

1) Functional Movement Development Across the Life Span, 2nd Edition
By Donna J. Cech and Suzanne "Tink" Martin - Elsevier

2) Neuroscience, 2nd Edition - Fundamentals for Rehabilitation
By Laurie Lundy-Ekman - Elsevier

[nari]

Flavio

Just some ideas - you are sounding hassled!:confused:

You describe robot movements, and I know what you mean by them. This is a bit of a bother, because one of the real challenges in NeuroRehab is what the patient does with his/her time when just at home or on the ward. When I left there was no answer for that one - and there still isn't, from my understanding.
Doing random movements is still movement, and if the stroke patient can just understand the need for movement, all would be better. But the dominance of the unaffected side is powerful, and it takes tremendous willpower (and an intact (R) hemisphere) for a patient to avoid use of the unaffected side. For many, that is not there. With no function on the affected side, the chances of a patient trying to avoid using only the unaffected side are poor, especially when cues are absent. Traditional exercises...I'm not sure what these are. Do you mean strengthening work, for which side? From what I can tell, there has been, and I suspect still is, conflict over the use of strengthening.
So you should not feel 'this is killing me' - controversy is rampant in pain rehab, and in the Neurorehab scene, and lots are confused over the optimal way to do things.
In my negative moments (and I had a few when in Neuro) I figured recovery is largely due to the brain's natural recovery process and my role is minimal. All we can do is keep learning and treat each stroke person as an individual, with individual needs. A functional focus still seems to be the way to go, in order to talk directly to the brain. Hands-off, except for physical support, is preferable, but in the big picture, hands-on for stimulation of ion-channels by touching is the new way of talking to the brain. Simple touching, nothing fancy, may work OK for the affected side, but I do not know its efficacy for stroke patients.

Neurorehab is the most challenging aspect of all physiotherapy. Never boring.
So keep going, and reading! We will never know all we need to know.

Nari

[rajulvasa]

Rajul,



When I say 'robot movement', I am trying to mean a movement that is performed in a flat way, and not as a 'Kabat way' (functional).


[color=#000000]

Because instead of doing nothing while in hospital, it is or may be better doing these 'old fashioned' exercises. Perhaps, and you have more authority than I to answer, even these kind of exercises are better than just electrical machines.

Well, Rajul, could you finish a doubt (is there another expression for this? some american, english or australian to help me? :teeth: ) of mine?



HI Flavio

I think it is more popularly known as PASSIVE MOVEMENT

[rajulvasa]

Rajul,
Does your way of approaching stroke patients have already been published or outlined in some journal or book? Or perhaps, do you know about some approach that looks like Vasa Concept? I am asking that because I am very curious about what in fact you do within your room to your patient... the way you treat him / her.
And just like you said to Bernard, this is killing me.

Kind regards,
Flávio.
PS: what do these two book mean for you?

1) Functional Movement Development Across the Life Span, 2nd Edition
By Donna J. Cech and Suzanne "Tink" Martin - Elsevier

2) Neuroscience, 2nd Edition - Fundamentals for Rehabilitation
By Laurie Lundy-Ekman - Elsevier

My Dear Flavio
U will have to wait for a while for Journal publication abouet VASA CONCEPT & for the stroke rehab book as well, it takes time when one needs to bring about a radical change in the present thinking. :thumbs_up
I believe only an article or two is not going to be enough, it will need much more & I am absolutely aware what music I might face! :secret: Therefore I will wait till time is ripe. But certainly I will be at UR disposal on Somasimple.

About the books u mentioned, sorry! I have not read them.

[flaviovitor]

...you are sounding hassled!:confused:


No, believe me. I am just anesthetised by the increasing knowledge in brain area. And for a clinician who intends to be up-to-date, it is no good being the latest in a row. :teeth:


...Traditional exercises...I'm not sure what these are. Do you mean strengthening work, for which side?


No, not special. Just doing hip, knee, shoulder, elbow, wrist, fingers, ankle flex / ext - inv / ever - etc. But without a intention. Just move to move. Move to achieve the ROM. What is the total opposite of funcional Rehab.

In my negative moments (and I had a few when in Neuro) I figured recovery is largely due to the brain's natural recovery process and my role is minimal.

But some studies show major brain plasticity, at least in animals, with active and functional rehab.


A functional focus still seems to be the way to go, in order to talk directly to the brain. Hands-off, except for physical support, is preferable, but in the big picture, hands-on for stimulation of ion-channels by touching is the new way of talking to the brain. Simple touching, nothing fancy, may work OK for the affected side, but I do not know its efficacy for stroke patients.

Except for the red, I agree 100%. Were you talking about in the red words about Barret Dorko?


Flávio.

[flaviovitor]

Rajul,

I will wait the book, CD / DVD, paper or anything else about your studies and maybe what can be named, a 'AVANT-GARD therapy'.

I was not meaning passive movement. The answer is in my Naris' thread response.

Regards,


Flávio.

[nari]

Flavio, I was meaning Simple Contact, as practised by Barrett Dorko. It would be most interesting to see how stroke people respond to SC, as it works so neatly with non-stroke people in resolving aches and dysfunctions. But I have no idea, until it is done, and I do suspect that there would be benefits, as it is direct communication with the brain itself.What you describe as traditional exercises (or, rather, movements) may or may not be helpful, I really don't know. Extensive studies in Australia in the 1980s demonstrated the unhelpfulness of 'stretching' the affected side and favoured positioning only (Carr and Shepherd, E Ellis, et al) but they were unclear about ordinary movements.

Nari

[Diane]

I remember Barrett Dorko mentioning watching Bobath handling people with strokes. I think he likely added what he learned/picked up from watching her, to his technique. I don't see why it wouldn't assist the stroked brain/movement impaired person to illuminate and reintegrate possible movement, given non-impairment in whatever crucial bits are essential, i.e., that such bits were left intact and are simply "offline", not destroyed.

[nari]

I would suspect there might be many bits and pieces 'offline' in the brain post-insult/trauma, and opportunity to recover may not necessarily happen if there is too much 'staged input' from therapists and others. Like strong persistent pain states, working out what would be ideal to enhance recovery is not easy, but the potential to stand back and let the jangled brain do its own movements (ie, with no orders/directions/'teaching' from the therapist, is high.

Rajul, is this what you are saying - in another way? Minimum input from therapist enhancing optimal output from the patient's brain?

Nari

[rajulvasa]

I would suspect there might be many bits and pieces 'offline' in the brain post-insult/trauma, and opportunity to recover may not necessarily happen if there is too much 'staged input' from therapists and others. Like strong persistent pain states, working out what would be ideal to enhance recovery is not easy, but the potential to stand back and let the jangled brain do its own movements (ie, with no orders/directions/'teaching' from the therapist, is high.

Rajul, is this what you are saying - in another way? Minimum input from therapist enhancing optimal output from the patient's brain?

Nari

Hi Nari
The Problem is "jangled brain do its own movements" & in my view therapist must guide & channalise this!

Minimum input from therapist enhancing optimal output from the patient's brain? Yes, minimum but apt input from therapist for exactly planned & desired output from the patient's brain & not chaotic & undesired output as is seen otherwise.

[bernard]

Flavio, Rajul and all SomaSimplers,

Is it possible to have a total recovery without our intervention? It exists ceratinly some favoured cases but the majority isn't.

We were trained with this ultimate concept: "If he/she do not move in the first year, it will not work!". I listened to Rajul and re-learned the brain plasticity.

How is it possible that an old (5 years) stroke patient with a lower limb orthosis, with a spastic upper one, is now able to walk without a crutch, able to bend his arm and control his tonus?

Patients need some clues and need to move in a good way. We have something to give in that way.

I was scared about this strange behaviour (spasticity) but now it seems quite easy to explain that often it is controlable and a first step to some voluntary motion.

[rajulvasa]

Flavio, Rajul and all SomaSimplers,

I was scared about this strange behaviour (spasticity) but now it seems quite easy to explain that often it is controlable and a first step to some voluntary motion.
Hi Bernard
Can u believe I was equally afraid of spasticity & also to handle the stroke patient 20years before!
I used to ask myself why the hell R U running away? Face it, bravely & intelligently BUT the feelings then, were: what must I do ? where to begin? I decided to travel around the world with ferrocious appetite to learn & find answers from the EXPERTS!
I went around the world with lots of expectations & what I discovered was highly disappointing, frustrating & shattering my inner self to face the next patient who would come to me with so much expectations without realising that he was coming to a professional who had no answer to his problem & had no guts to say I do not know as I was certified to officially treat him!
State of my mind was almost devastating as I did not like to run away from my responsibility & at the same time there was no thread to begin!
During this storming existance as professional, I was also watching how much insecurity & inferiority complex the therapist around the world lived with ofcourse it was never expressed verbally openly but it reflected in their behavior in comparision to the doctors!
I thought that stroke is an area of unchartered waters & nobody really knows what is going on & why & as U DESCRIBED IT IT WAS UNWRITTEN RULE IF ONE DID NOT MOVE IN A YEAR, HE OR SHE WAS LESS LIKELY TO MOVE!
I realised that so called medical experts & opinion makers R also only endorsing upon the opinion of the previous expert & it looked as if all r only supporting each other's failure! that is stroke is a story of reaching to a dead end!
These opinion makers found one psychological escape from responsibility by referring the patient to physiotherapist saying, exercises r very important, go to therapists but come back to us to get certified by us as we know more as doctors then therapist! Therapists R simply technicians to help u & assist u to move when u can not! It is we who can tell
1) how much u have recovered!
2) If u R walking with aid, u r lucky
3) If u r walking without aid but badly no worry u r still very lucky, continue physiotherapy & gait training
4) worried about hand? Do not! it takes time!
5) Worried about pain? do not, we have pain killers.
6) Worried about subluxation? do not it is part & parcel of the condition & many get it, U R not the only one so please do not worry! we have slings & supports available!
7) worried about spasticity? do not ! we have Botox to selectively paralyse UR muscle which is a victim of CNS lesion! U had one problem, that we can not solve, so we give u another one by local paralysis of muscle with botox!
8) After so much physiotherapy u do not recover as expected by u, sorry u r unlucky & if u expect to become what u were before then, u r joking it is nver possible for a stroke patient!

I was watching the scene silently & realised that if patient recovered then it was natural recovery & from healing of the brain. If recovery was long after the stroke it was due to plasticity!
Unfortunately experts are skeptical about therapeutic recovery! it is always challenged or doubted !
Stroke patients are sent to physiotherapy depts for convinience, to answer the insurance guys & for several other reasons, mobilise enough for the patient to get ready to be discharged for home or for special care centres, wheel chair training,gait training! maintenance etc BUT for sincere & true belief in therapeutic recovery of the affected musculoskeletal system despite CNS damage.
Time has come we therapists will continue to stand in our own shoes but with pride to see that the medical experts accept to announce that solution lies in the hands of therapist & affacted MSS can become functional again therapeutically & therefore the patient is referred to therapy & not for compensation & maintenance & not for meeting functional goal with altered movements.

[Diane]

Wow Rajul!! That post is so succinct, honest-sounding, and such a clear description of what each PT goes through. It really is SUCH a grey zone, neuro rehab. Good for you for spelling it out like that, and your quest and for finding your feet in this regard.

On a slightly different topic, a few years ago 'constraint induced' neural plasticity/functional recovery was a big deal, a buzz surrounded it. I have no idea how widespread the practice was, but patients with strokes were not allowed to use their unaffected hand for anything. They had to wear a catcher's mitt on it, and if they wanted to do anything they had to figure out a way to do it with the stroke side hand. I remember reading that it took several weeks, results were promising, but that the several hours a day of therapy made it a bit difficult in terms of cost effectiveness. What is your take on that?

[bernard]

Here is an interesting paper?

Although still preliminary, the findings overall suggest that it is possible to influence motor network reorganization after stroke by motor training procedures and that training-induced brain plasticity is possible not only in subacute but also in chronic stroke patients, ie, the time elapsed since stroke onset does not appear to be a limiting factor for this effect.

[emad]

Hi Raj:

I have not read the whole thread , just the few last ones.

Spasticity .
i meet many cases ,daily i encouter post stroke patients .

I consider my role ,helping the patient to move independantly ,helping himself/herself , but regarding the upper limb ,enough for me to avoid entering in flexor synergy spasticity ,but the function almost in high percentage is lost .

I meet ,considreable number who practised physio in another palces ,come to me after 1 year with severe spasticity , i refuse to contuine with them .

I can NOT bear those cases of severe spasticity .

Regards

Emad

[bernard]

Here two papers for Diane (and all :lightbulb)

Constraint-induced movement therapy for people following stroke in an outpatient setting

An Application of Upper-Extremity Constraint-Induced Movement Therapy in a Patient With Subacute Stroke

[bernard]

I can NOT bear those cases of severe spasticity.

I was like you, a year ago but I changed. Just try.:lightbulb

[rajulvasa]

Wow Rajul!! That post is so succinct, honest-sounding, and such a clear description of what each PT goes through. It really is SUCH a grey zone, neuro rehab. Good for you for spelling it out like that, and your quest and for finding your feet in this regard.

Hi Diane
Now I am obcessed to reach to a new shore & find a new land for neuro rehab patients & therapists to exclaim & shout together " Wow it is no longer a greyzone" BUT is "green all over!"

[nari]

I have only caught up with this thread again - didn't look at the date closely enough.

Thanks for your post on your trials and tribulations with neuroRehab, Rajul. Even when I left the area in 2002, the neurologists were still saying : if no recovery within three months, there will be none - or at least no function. Up till about 1992 physiotherapists went along with that, and due to increased pressure to 'empty beds', set about making the patient as mobile as possible with all sorts of gadgets - splints, knee braces, wheelchairs, sticks, frames and left it at that. There was no opportunity to do any follow up. A few stroke outpatients attended for a 'trial' of physio, but only those who were steadily recovering. That all changed when a system was set up in the community where strokes were seen for limited sessions, to progress their status. The emphasis remained on keeping the patient safe, so walking aids and millions of OT aids were set in place.
Whatever I instigated in the acute ward was not carried out in the Rehab ward. I was disgusted at times to see a) a patient who had been walking short distances, instantly given a wheelchair with which to mobilise...the rationale being that access to the courtyard and gardens was important. Of course most remained in the wheelchair; and b) a patient who was managing slowly walking about 200 m by him/herself, would be given a four point stick 'for safety' and to 'improve mobility'. Of course the whole gait changed to a stilted, robotic gait....I had a few colleagues who agreed with me, but generally - it was to prepare them for a life of handicap.

Re constraint therapy - it has been around for a long time, and I used it fairly often, with stroke persons who had some return in the affected arm. But it had its hassles; the relatives were often upset by the constraint, and even after education and signed consent, they would surrender to sentiment and ask that it not be done. In some cases, it worked very well, and recovery was speeded up. I did not use it on (R) strokes, only on left when I was certain that they knew what was going on. There were a few patients who insisted to their relatives that it be done routinely - they improved faster. The OTs also used it.

When I left in 2002, the opportunity for recovery was open-ended, to months, years. A review system was set up to look for increased function/movement, but it fell over due to lack of funding. Back in 1990, I had as an outpatient, a stroke person who had no movement in his left arm 6 years after the event. He had fallen in the driveway and fractured his unaffected arm - out of commission for at least 6 weeks, or longer, as it was a complex HOH #. he was totally disbaled and was sent to physio 'for intense physio to the right arm to restore function'. In the meantime, he had been involuntarily constrained, and there were signs of movement in the hemiplegic arm (which was hypertonic). So I didn't worry about his (R) arm much and set about facilitating recovery in the (L). Most PTs thought I was crazy, and wasting precious outpatient time; after all one should not "do Rehab" in an outpatient setting....

Within three months, he had enough return in the left to use both arms usefully. A few months later, he drove alone to another city, about 700 km away. He called back to see me, and his (L) 'useless' arm had almost totally recovered, except for a tendency for the DIPs to flex. He was back at work, driving, swimming, and could hug his wife 'properly'.
That convinced me for good...never ever, if possible, give up on a stroke as long as cognition is OK. Fortunately, his was intact.
Even better, he gave me a magnum of French cognac.....:D


Nari

[rajulvasa]

- it was to prepare them for a life of handicap.
Within three months, he had enough return in the left to use both arms usefully. A few months later, he drove alone to another city, about 700 km away. He called back to see me, and his (L) 'useless' arm had almost totally recovered, except for a tendency for the DIPs to flex. He was back at work, driving, swimming, and could hug his wife 'properly'.
That convinced me for good...never ever, if possible, give up on a stroke as long as cognition is OK. Fortunately, his was intact.
Even better, he gave me a magnum of French cognac.....:D
Nari

Congratulations Nari
Individual positive experiences of dedicated therapists will form a chain that gets longer each day to become difficult to NOT get noticed.

Hunger for bringing the change in the field of Neuro rehab is ever increasing at the same time the old gurus r not happy to see the change coming in! May be wasted interest? If No one wants to learn an old technique who will attend courses & seminars & who will buy those educating videocassettes?

I wonder who will take a lead to oppose to prepare them for a life of handicap?

I wonder how the systematically organized system of fancy toys promoted officially as the mandatory needs in Neuro rehab will be uncovered to see the underlying naked truth

[emad]

Bernard ;

I am following the thread .


Regards
Emad

[rajulvasa]

Hi Emad
Good job done in finding these CONTRADICTING interesting article.
The second article means a lot.
Now people do not follow blindly, evidences are also challenged with evidence.

[Diane]

Sounds like the intact cognition is the essential key for starting the inner brain neural plasticity process. (Maybe through gamma binding..:) )

[emad]

Diane ;


What is that gamma ?


Emad

[nari]

Contradictory articles are fun - they tend to disrupt sheep!

Constraining a limb where the stroke has affected executive functioning and cognition in general, would seem pointless, which is why I never did it. Unless a person KNOWS why something has happened to alter ability to do things, he/she would just experience extreme anger or give in and do absolutely nothing. It is also interesting to note that (R) strokes can also experience total loss of unilateral awareness with spatial neglect, and that this can occur in both hemispheres (watershed effect).
Awareness seems to be a key factor in the use of constraint and its success or failure, so maybe the gammas are crucial in this....


Nari

[Diane]

Emad, check out the gamma thread in the "genius brain" forum.

[rajulvasa]

Sounds like the intact cognition is the essential key for starting the inner brain neural plasticity process. (Maybe through gamma binding..:) )
Hi Diane
I have experienced maximum rigidity in the minds of the Neurologists around the world. Some of them are not even interested in what happens to the neuro patient after the diagnosis is done, as if one is dealing with some commodity & not human life! Some of them are so strongly negative about the outcome that they influence the mind of the patient in the wrong sense to start with & then the patient lands up with therapist with preconceived ideas making the job of therapist difficult & patient also believes in the medical doctor more then in therapists!
some spasticity in the minds of some guru's in physiotherapy is also known for their expectations for stroke outcome. Just imagine the state of the patient when his doctor as well as the therapist have negative approach & least expectations or fixed ideas without any room for (Maybe gamma binding..:)

[nari]

Actually, hypertonicity never worried me - it registered as a good thing, rather like pain in the context of evolutionary biology. Flaccidity, on the other hand always seemed ominous..and if it persisted for weeks, it often indicated a poor outcome. Our neurologists, fortunately, were cognisant of the fact that physios know more about rehab than they did...BUT two of the three seemed hell-bent on making gloomy predictions to the patient after a fortnight or so. It certainly annoyed me. Once I challnged one of them (I got to know them well).."do you realise the negative effect of what you just told Mrs X?" The reply was: "Better to tell the truth than raise false hopes." I said something along the lines of how did he know that would be the truth? and he shrugged his shoulders with a smile. "Prove me wrong...I'd be so glad if you could"...and sauntered off.....

Enigmatic characters, doctors..

Nari

[bernard]

Nari,
Some Doctors have not yet evolved!
http://www.somasimple.com/images/doctors2.jpg

[Diane]

Rajul, it's the same story with pain patients. Or ortho. Or anything. Sad...

[rajulvasa]

Actually, hypertonicity never worried me - it registered as a good thing, rather like pain in the context of evolutionary biology. Flaccidity, on the other hand always seemed ominous..and if it persisted for weeks, it often indicated a poor outcome. Our neurologists, fortunately, were cognisant of the fact that physios know more about rehab than they did...BUT two of the three seemed hell-bent on making gloomy predictions to the patient after a fortnight or so. It certainly annoyed me. Once I challnged one of them (I got to know them well).."do you realise the negative effect of what you just told Mrs X?" The reply was: "Better to tell the truth than raise false hopes." I said something along the lines of how did he know that would be the truth? and he shrugged his shoulders with a smile. "Prove me wrong...I'd be so glad if you could"...and sauntered off.....

Enigmatic characters, doctors..

Nari
It means there are more Enigmatic characters then I believed:cry:

[rajulvasa]

Rajul, it's the same story with pain patients. Or ortho. Or anything. Sad...

It means there are more Enigmatic characters then I believed:angry:

We have on hand a marathon task. First, to change doctor's perception on our actions, & their strong belief in their diagnosis as the ultimate truth & therapists as mere followers as technicians!:angry: & second, to give results as actions speak louder than words!:)

[rajulvasa]

Actually, hypertonicity never worried me - it registered as a good thing, rather like pain in the context of evolutionary biology. Flaccidity, on the other hand always seemed ominous..
Nari
In my experiences spasticity is not a good thing & flaccidity is not ominous.
Both are mostly misunderstood.

[emad]

Raj :

Whare do you practise neurophysio??
The issue sometimes is individualised ,not all doctors act like that ,not all therapists accept that ( some therapist accept being in second position for just receiving the patients from doctors) ,then just give a look from another aspect ,if we were in their postions ,would we act like them .The definate answer will be yes , we would ,for only simple reason ,feeling of existance ,what is he/she is going to say after the patient spent long time with the therapist ,that is a natural react , there is must be something to say :shade: :zip:

Another point acted to make thus issue so clear , the patient s level of understanding of the difference between therapist and physician role .


Regards

Emad

[rajulvasa]

Raj :

Whare do you practise neurophysio??
Another point acted to make thus issue so clear , the patient s level of understanding of the difference between therapist and physician role .

Regards
Emad
Hi Emad
I live & practice in Mumbai INDIA
My views are normally centered around stroke & Neurologist's perception about stroke rehab.
Stroke patient is seen by therapist for more number of hours & for a long period of time unlike role of Neurologist in diagnosing & taking care of acute condition.

[Diane]

May I ask you your age Rajul, and how long you've been a therapist? I ask not to be nosy but because I found in myself (35 years a therapist) that it takes a long time (at least it did me) to have enough seasoned experience to know for sure what to toss and what to keep, which direction to boldly stride into, who was worth tracking and who was seriously inflating their own ego, who was genuinely interested in helping people (therapeutic) and who was being a career builder by developing a cult. It sounds like you've been around awhile if you've done all that travelling and searching and sifting.

[emad]

Nari , putting that article ,however i do not like dirputing peacful sheep.;)

Raj;

you are right regarding ,the issue of time being spend with the stroke consumer , lately i put a topic regarding the Visiting basis , however i meant the pain patient , the isuue for stroke /paralysis is different we need to move more , instruct more ,speak more , assist more ! why not ! sepnd more take more money ! you have the right to be angry in one case if the fees of 10 session neurophysio equals one doctor fees visit !!!!!????

yes, you are right , you concern more the patient view , regarding who get you more , the therapist or the doctor , that is a cultural and a level of civilisation .

Have you found the same issue in india and in Europe ???


Emad

[rajulvasa]

Nari , putting that article ,however i do not like dirputing peacful sheep.;)

Raj;
you have the right to be angry in one case if the fees of 10 session neurophysio equals one doctor fees visit !!!!!????
Emad
Emad
I can assure u that, time will come when a stroke therapist will charge more than doctors per visit.
I already do that

[nari]

Hi Rajul and others

An interesting thought crossed my mind today as i was reading the latest edition of Scientific American Mind Vol 16 #3. There is an article Spinal Cord Repair with the following words: (in the context of regenerating/repairing lost body functions such as quads and paras, looking at both glia and neurons)

Quote:..."Schwab of Zurich notes that ...investigators who have tried to combine different healing schemes have had discouraging results. Even in animal tests, combination therapies proved to be extremely complex. This bare fact highlights a disturbing facet of spinal cord research: much of it is bieng conducted under a spotlight of publicity..... trying a treatment too soon (before adequate testing) (my italics) not only raises false hopes, it can cause phantom pain from new nerve pathways that make improper connections."

What then occured to me, not in the sense of anything being regenerated immediately post-stroke, but the classic hemiplegic pain that can follow within days of the stroke...might it not be phantom pain, a recognition of limb loss?
in which case...managment of post-stroke patients could take on a whole
'new' meaning. :eek:
The fact that not all amputees develop phantom pain, and not all stroke patients develop shoulder pain either...does suggest some interesting venues to explore...

Nari

[rajulvasa]

Hi Rajul and others
An interesting thought crossed my mind today as i was reading the latest edition of Scientific American Mind Vol 16 #3. There is an article Spinal Cord Repair with the following words: (in the context of regenerating/repairing lost body functions such as quads and paras, looking at both glia and neurons)

Quote:..."Schwab of Zurich notes that ...investigators who have tried to combine different healing schemes have had discouraging results. Even in animal tests, combination therapies proved to be extremely complex. This bare fact highlights a disturbing facet of spinal cord research: much of it is bieng conducted under a spotlight of publicity..... trying a treatment too soon (before adequate testing) (my italics) not only raises false hopes, it can cause phantom pain from new nerve pathways that make improper connections."
What then occured to me, not in the sense of anything being regenerated immediately post-stroke, but the classic hemiplegic pain that can follow within days of the stroke...might it not be phantom pain, a recognition of limb loss?
in which case...managment of post-stroke patients could take on a whole
'new' meaning. :eek:
The fact that not all amputees develop phantom pain, and not all stroke patients develop shoulder pain either...does suggest some interesting venues to explore...
Nari

Shoulder pain in stroke patient is not central pain at all & is not recognition of limb loss!
In my experiences, generally the shoulder pain is the result of mis handling a very flail & floppy shoulder. Highly sensitive shoulder capsule richly supplied with nerve endings comes under stress & strain to precipitate agonising pain which can be completely removed if taken care without passive exercise therapy & ofcourse meaningless shoulder sling.
Ofcourse strong fear in the minds of therapist for possible subluxation & dislocation makes the therapist extra defensive & protective,advices rest to the part & patient senses it as a delicate issue, for the saga of
useless extrimity to begin.
Plastic changes that happen in the stroke CNS, can have negative effect as much as positive

About paraplegics & quadriplegics we will discuss at right time.

[nari]

Rajul

I appreciate your reply, and it is generally assumed that shoulder pain arises from poor handling, but not ALL flaccid limbs develop pain, or even hypertonic ones. To my knowledge no studies have been done to demonstrate a strong relationship between poor handling and hemiplegic pain.

It is also known that subluxed HOHs do not always result in pain.
I think that pain is pain, regardless of what has happened to the patient. To my way of thinking, the brain will decide what is a threat and what is not; and act accordingly. Maybe in the case of a (R) stroke, where cognition is affected, the issue becomes more complex - I don't know.

Nobody does passive movements anymore, and have not done for years, so that cannot be a 'cause'.
I certainly would not argue that plasticity can mean negative as well as positive changes - which fits into my statement originally - I think, anyway.


Nari

[bernard]

In my experiences spasticity is not a good thing & flaccidity is not ominous.
Both are mostly misunderstood.

I haven't such experience you have about these two "bad" but I think (my opinion) that flaccidity is an over conrolling process from brain on spinal cord and spasticity is a loss/diminution of brain control over spinal cord?

[rajulvasa]

I haven't such experience you have about these two "bad" but I think (my opinion) that flaccidity is an over conrolling process from brain on spinal cord and spasticity is a loss/diminution of brain control over spinal cord?

Bernard
U R tempting me to say something which might become very controversial until I support it with the evidences so let us wait for a while.

But I can say one thing that flaccidity is a lesser evil than spasticity & atleast u r starting, not on a negative footing when u see a flaccid patient.One definately has more chances & more possibilities.
In my experience I enjoy to treat floppy & flaccid over spastics as I can mould the CNS recovry as I like & there is no speed breaker on my pathway to recovery of MSS.

To me when u encounter spasticity, u r starting on a negative footing & it also means CNS is reorganised wherein natural CNS recovery is wasted without canalizing into MSS recovery for desired function.

[bernard]

Rajul,

It is just my silly conclusions?
spinal cord engages spasticity?
Brain engages flacidity?
The result is movement?

[rajulvasa]

Rajul,

It is just my silly conclusions?
spinal cord engages spasticity?
Brain engages flacidity?
The result is movement?
Bernard
Brain & nature works on very simple fundas. we complicate the simple, then get confused & then easily give up announcing that Brain is a complex dark box.
Compartmentalizing & dividing & finding special role of brain structures is man made invention to figure out what brain is upto. It helped but also created boundaries.

Spasticity & flaccidity are terms for our universal recognition & simplification.

For the brain, priority is to survive & it can use apt tools in self benefit.
For an animal brain to survive from predator it can run for life! (movement)
or some can choose to freeze & stand still.
(no movement, Spasticity? No movement because of flaccidity?) r all the terms we use for labeling, generalising,compartmrntalizing,to get confused?
Brain continues its mission without bothering to know what is our perception of it, may be it laughs when it sees us confused about it most of the time!:cool:

[rajulvasa]

Rajul

I appreciate your reply, and it is generally assumed that shoulder pain arises from poor handling, but not ALL flaccid limbs develop pain, or even hypertonic ones. To my knowledge no studies have been done to demonstrate a strong relationship between poor handling and hemiplegic pain.

It is also known that subluxed HOHs do not always result in pain.
I think that pain is pain, regardless of what has happened to the patient. To my way of thinking, the brain will decide what is a threat and what is not; and act accordingly. Maybe in the case of a (R) stroke, where cognition is affected, the issue becomes more complex - I don't know.

Nobody does passive movements anymore, and have not done for years, so that cannot be a 'cause'.
I certainly would not argue that plasticity can mean negative as well as positive changes - which fits into my statement originally - I think, anyway.
Nari

Flaccidity or spasticity per se is not the cause for pain, it helps trigger & it does not mean it will always.
Passive movements r done freely by nurses while giving bed positioning.
Doctors want to asses tone & power in upper limb,freely handle passively in acute & sub acute stage.

[rajulvasa]

Author: Aras, M. D.; Gokkaya, N. K. O.; Comert, D.; Kaya, A.; Cakci, A.


Year: 2004







Title: Shoulder pain in hemiplegia: results from a national rehabilitation hospital in Turkey







Journal: American Journal of Physical Medicine and Rehabilitation







Volume: 83







Issue: 9







Pages: 713-9







Alternate Journal: Am J Phys Med Rehabil







Abstract: OBJECTIVE: Shoulder pain is a common complication after stroke that can limit the


patients' ability to reach their maximum functional potential and impede rehabilitation. The aim of our study was to examine the occurrence of hemiplegic shoulder pain in a group of Turkish patients and clarify contributing factors such as glenohumeral subluxation, reflex sympathetic dystrophy, tonus changes, motor functional level, limitation in shoulder range of motion, thalamic pain, neglect, and time since onset of hemiplegia. The effect of shoulder pain on the duration of rehabilitation stay was also identified. DESIGN: A total of 85 consecutive patients with hemiplegia admitted to a national rehabilitation center were evaluated for the presence of shoulder pain. A brief history of pain was taken for each patient, and each patient was evaluated by radiographic and ultrasonographic examination. The subjects with shoulder pain were compared with those without pain in regard to certain of the above variables. RESULTS: Of the 85 patients with stroke, 54 patients (54/85, 63.5%) were found to have shoulder pain. Shoulder pain was significantly more frequent in subjects with reflex sympathetic dystrophy, lower motor functional level of shoulder and hand (P < 0001), subluxation, and limitation of external rotation and flexion of shoulder (P < 0,05). Age was also a significant factor in the development of shoulder pain. We were unable to demonstrate a significant relationship between shoulder pain and sex, time since onset of disease, hemiplegic side, pathogenesis, spasticity, neglect, and thalamic pain. There was no prolongation of rehabilitation stay in patients with shoulder pain. CONCLUSION: These results indicate that shoulder pain is a frequent complication after stroke and that it may develop from a variety of factors. To prevent and alleviate shoulder pain, efforts should be directed toward proper positioning of the shoulder, range of motion activities, and the avoidance of immobilization.

[rajulvasa]

Author: Pandyan, A. D.; Cameron, M.; Powell, J.; Stott, D. J.; Granat, M. H.

Year: 2003

Title: Contractures in the post-stroke wrist: a pilot study of its time course of development and its

association with upper limb recovery

Journal: Clinical Rehabilitation

Volume: 17

Issue: 1

Pages: 88-95

Alternate Journal: Clin Rehabil

Abstract: BACKGROUND: Contractures are common in a stroke population, yet there is little

information on the time course of development. OBJECTIVES: Investigate quantitatively changes associated with contracture formation in an acute stroke population. STUDY DESIGN: Longitudinal study on 22 subjects who were 2-4 weeks post stroke. OUTCOME MEASURES: Contractures were assessed by quantifying the resting posture, resistance to passive movement and passive range of movement. Upper limb function was measured using the Action Research Arm Test and the Nine-Hole Peg Test. Active range of extension, wrist extension strength (isometric), grip strength and neglect were also measured. REPEATED MEASURES: Following an initial assessment, repeated measurements were taken at 4, 8, 20 and 32 weeks after recruitment.RESULTS: Two distinct subgroups, one capable of some functional movement (F group; 8subjects) and another which was not (NF group; 14 subjects), were identified at the start of thestudy. The NF group showed changes associated with contracture formation at the wrist, i.e., reduction in the passive range of movement, an increase in resistance to passive movement and a worsening of the flexion posture. Changes were observed from the time of recruitment even though neglect improved. The F group showed improvements in upper limb function and there was no evidence to support contracture formation. CONCLUSIONS: Subjects most prone to contracture formation were those who showed no signs of early functional recovery (2-4 weeks after the stroke). Changes consistent with adaptive shortening were seen from week 4 of the study period.

[rajulvasa]

Author: Turner Stokes, L.; Jackson, D.







Year: 2002







Title: Shoulder pain after stroke: a review of the evidence base to inform the development of an







file:///I:/HTML/bobathnet/engl/e_literatur/bobathcinahl.htm







integrated care pathway







Journal: Clinical Rehabilitation







Volume: 16







Issue: 3







Pages: 276-98







Alternate Journal: Clin Rehabil







Abstract: BACKGROUND: Shoulder pain is a common complication of stroke. It can impede rehabilitation and has been associated with poorer outcomes and prolonged hospital stay. Thissystematic review was undertaken to inform the development of an evidence-based integrated care pathway (ICP) for the management of hemiplegic shoulder pain (HSP). AIMS AND


OBJECTIVES: 1) To provide a background understanding of the functional anatomy of theshoulder and its changes following stroke. 2) To review the literature describing incidence and causation of HSP and the evidence for factors contributing to its development. 3) To appraise the evidence for effectiveness of different interventions for HSP. METHODS: Data sources comprised a computer-aided search of published studies on shoulder pain in stroke or hemiplegia and references to literature used in reviews (total references = 121). MAIN FINDINGS: Although a complex variety of physical changes are associated with HSP, these broadly divide into 'flaccid' and 'spastic' presentations. Management should vary accordingly; each presentation requiring different approaches to handling, support and intervention. (1) In the flaccid stage, the shoulder is prone to inferior subluxation and vulnerable to soft-tissue damage. The arm should be supported at all times and functional electrical stimulation may reduce subluxation and enhance return of muscle activity. (2) In the spastic stage, movement is often severely limited. Relieving spasticity and maintaining range requires expert handling; overhead exercise pulleys should never be used.

Local steroid injections should be avoided unless there is clear evidence of an inflammatory lesion. CONCLUSIONS: HSP requires co-ordinated multidisciplinary management to minimize interference with rehabilitation and optimize outcome. Further research is needed to determine effective prophylaxis and document the therapeutic effect of different modalities in the various

presentations. Development of an integrated care pathway provides a asoned approach tomanagement of this complex condition, thus providing a sound basis for prospective evaluation of different interventions in the future.

[nari]

Rajul

Do these studies confirm that poor handling of the affected shoulder in the acute/subacute stage results in pain generation? I don't think so. The percentage of those with pain is about what is 'average' for strokes here, and passive movements are not done; nurses and doctors have been educated on that aspect. Apart from that, there is nothing new in these studies that hasn't been known for a long time. but a study can be done to show the problem exists and its management without an understanding of the role of central or even peripheral sensitisation...thalamic pain is a misnomer now, as we know that there are many sites in the brain which interpret afferent messages and generate pain. I think this could be considered as a reason for shoulder pain/loss of ROM, that is all I meant.


Nari

[rajulvasa]

Rajul

Apart from that, there is nothing new in these studies that hasn't been known for a long time.
Nari

Nari this is what precisely I am trying to indicate,that in 21st century, the direction of research is still maintained what was happening in eighties.


but a study can be done to show the problem exists and its management without an understanding of the role of central or even peripheral sensitisation...
Nari
New direction is the need of the hour.

[rajulvasa]

Rajul

passive movements are not done; nurses and doctors have been educated on that aspect.
Nari
Nari
U R absolutely right that passive movements r not done as part of treatment, not by nurses not by any body BUT passive handling is definately done for dressing, undressing, bathing etc.
Acute stroke patient is also moved passively while taken to different departments for investigation like for CT & MRI & doppler etc. Shoulder can be mis handled by anybody during these events.
Bed positioning is also considered to be extremely important by some schools of physios & nurses & family is asked to cooperate for preventing future contracture by positioning in bed!