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Textbook of Neural Repair and Rehabilitation
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Book description

In two freestanding but linked volumes, Textbook of Neural Repair and Rehabilitation provides comprehensive coverage of the science and practice of neurological rehabilitation. This volume, Medical Neurorehabilitation, can stand alone as a clinical handbook for neurorehabilitation. It covers the practical applications of the basic science principles presented in volume 1, provides authoritative guidelines on the management of disabling symptoms, and describes comprehensive rehabilitation approaches for the major categories of disabling neurological disorders. Emphasizing the integration of basic and clinical knowledge, this book and its companion are edited and written by leading international authorities. Together they are an essential resource for neuroscientists and provide a foundation for the work of clinical neurorehabilitation professionals .

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Contents

Page 1 of 2

Contents
  • 1 - Outcomes measurement: basic principles and applications in stroke rehabilitation
    pp 5-23
  • View abstract

    Summary

    This chapter introduces basic concepts related to the development of outcome measures, and demonstrates their applications in stroke rehabilitation. Measures used to evaluate the outcomes of rehabilitation for individuals with stroke generally reflect physical, psychologic, or social characteristics of people. Other constructs one might want to assess include impairment, ability/disability, community mobility, health status, self-efficacy, fitness, participation or quality of life. Such constructs are evaluated using standardized scales. The evaluation of walking competency after stroke is used as an example to illustrate the selection of appropriate outcome measures for this population as well as their relation to participation. The chapter illustrates how laboratory outcome measures can be used to validate clinical measures, explain the results of clinical outcomes, develop new measures, and guide therapy. With the rapid development of neuroimaging techniques, it has become possible to study neural organization associated with motor recovery after brain damage.
  • 2 - Human voluntary motor control and dysfunction
    pp 24-36
  • View abstract

    Summary

    This chapter explains how areas of the cerebral cortex and their descending pathways contribute to voluntary motor control in humans in the context of how these areas provide compensatory control for each other in the damaged brain. It reviews evidence that supports the current, more complex view of primary motor cortical (M1). The chapter discusses how the current view indicates that M1 is a flexible control system with an inherent capacity for plastic reorganization after brain injury. The non-primary motor cortical areas (NPMAs) are well-suited to provide compensatory control of voluntary movement after damage to M1. Motor control signals from M1 and the NPMAs travel to the spinal cord via several descending tracts. The corticospinal tract is the most direct pathway from the cerebral cortex to the spinal motoneurons. Finally, the chapter shows how spared territories and tracts might affect the capacity for functional recovery of movement.
  • 3 - Assessments, interventions, and outcome measures for walking
    pp 37-47
  • View abstract

    Summary

    Faster and more functional walking reduces risk factors for cardiovascular disease, recurrent stroke, and frailty by permitting opportunity for exercise and fitness. Interneuron-linked oscillators within the lumbar cord for flexion and extension of the hindlimbs, called central pattern generators (CPGs), have become a target for locomotor training interventions and neural repair. Rationales for gait retraining in patients draws from animal models about specific sensory inputs that aid the timing and efficacy of the step cycle. The gait cycle is assessed by educated observational skills and knowledge of the disease and its resulting symptoms and impairments. Strategies for retraining gait start with interventions to improve control of the head and trunk when necessary, then proceed to sitting and standing balance. Whether an individual patient is in rehabilitation as an inpatient or outpatient or participating in a clinical trial, sensitive and reliable outcome measures determine the success of an intervention for walking.
  • 4 - Electromyography in neurorehabilitation
    pp 48-55
  • View abstract

    Summary

    One of the fundamental principles of electrodiagnostic medicine is the assessment of the peripheral nervous system's ability to conduct an electrical impulse. Nerve conduction studies (NCs) and needle electromyography (EMG), are commonly referred to as electrodiagnostic or EMG studies. The primary goals of the EMG study are to localize the lesion, characterize the underlying nerve pathophysiology, quantitate the severity of the lesion, and assess the temporal course of the disorder. Weakness can be secondary to a lesion in the upper motor neuron pool or within the lower motor neuron pool. Some patients may, in the course of their rehabilitation, develop a pattern of proximal weakness. This weakness usually begins in the lower extremities and then progresses to involve the proximal arms. Surface EMG (SEMG) can provide a simple, noninvasive method to assess the activation of muscles involved in performing specific tasks.
  • 5 - Functional neuroimaging
    pp 56-68
  • View abstract

    Summary

    Patients, who survive focal brain injury for example stroke, undergo complete or more commonly partial recovery of function. There is a growing interest in designing therapeutic strategies to promote cerebral reorganisation as a way of reducing rather than compensating for impairment. Positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) rely on the assumption that neuronal activity is closely coupled to a local increase in cerebral blood flow (CBF) secondary to an increase in metabolism. Functional MRI comprises different methods, but the studies described in this chapter use blood oxygen level-dependent (BOLD) imaging techniques. The interpretation of functional imaging data from patients with brain lesions will be influenced by the site and extent of lesions. Voxel-based morphometry (VBM) and diffusion tensor imaging (DTI) techniques provide accurate objective anatomical data that can be used to address hypotheses about the structure-function relationships of surviving brain regions.
  • 6 - Cell transplantation therapy for Parkinson's disease
    pp 71-88
  • View abstract

    Summary

    Parkinson's disease (PD) patients can suffer intolerable disability despite currently available therapies, and a treatment that slows disease progression and/or restores function is an urgent priority. Much attention has focused on transplantation strategies as a treatment option because of the potential of transplanted dopamine nerve cells to replace degenerating dopamine neurons. The first studies of transplantation in humans utilized autologous adrenomedullary cells implanted into the caudate nucleus. Variables that must be considered in developing a transplant protocol include method of tissue storage prior to surgery, donor age, number of donors implanted, site of transplantation, type of transplant, and the use of immunosuppression. To better define the safety and efficacy of fetal nigral transplantation as a treatment for PD, the National Institutes of Health in the USA supported two double-blind, placebo-controlled trials. Transplantation of fetal mesencephalic dopamine neurons was associated with a potentially disabling off-medication dyskinesia.
  • 7 - Conditions of task practice for individuals with neurologic impairments
    pp 89-102
  • View abstract

    Summary

    This chapter provides a scientific rationale for choosing the conditions of practice that best promote skill learning in the context of task-specific training for diminished functional ability in the neurologically impaired patient. It defines skill and motor learning within the context of neurorehabilitation. Motor learning is a set of processes associated with practice or experience leading to relatively permanent changes in the capability for responding. The chapter discusses the differences between use and skill as these terms apply to upper extremity (UE) and manual actions. It argues that this distinction becomes important for choosing the appropriate conditions of practice for individuals post-stroke. The chapter reviews the literature pertaining to two important conditions of practice known to be critical for motor skill learning: augmented feedback and explicit information and task scheduling. Finally, it outlines how these conditions might be manipulated to promote recovery of functional skills in the neurologically impaired patient.
  • 8 - Balance training
    pp 103-118
  • View abstract

    Summary

    Balance, a skill required to maintain upright posture, has both orientation and stability components. A postural control strategy is selected to achieve the desired body orientation and a copy of the control strategy is fed to the internal models to yield estimated orientation and expected sensory afferent signals. This chapter covers two resources that are crucial for balance control are sensory strategies and movement strategies. Nagi's disablement scheme is a helpful model to use in approaching balance assessment, the first step in balance rehabilitation. Just as assessment of balance is multifactorial, so is treatment of balance disorders. Many different approaches have been used to treat balance disorders, including generalized exercise programs, balance-specific exercises, training of postural strategies, sensory organization training, biofeedback, and environmental modifications paired with education. Through careful assessment and treatment, it is possible to significantly improve balance and reduce fall injuries in individuals with Parkinson disease (PD).
  • 9 - Functional electrical stimulation in neurorehabilitation
    pp 119-135
  • View abstract

    Summary

    This chapter examines both the therapeutic aspects of functional electrical stimulation (FES) as well as the direct functional applications as it is applied to individuals with neurologic injury. FES systems typically consist of three major components. First, there is a control mechanism. Second, there is an electronic stimulator, which may be external or implanted. Third, there are electrodes that allow for interface between the stimulator and the nervous system. There are several important parameters that can be adjusted during FES application, including pulse waveform, amplitude, duration, frequency, charge, and modulations. The option of interrupted pulses is mandatory in most neurorehabilitation clinical applications. Functional uses for FES after spinal cord injury (SCI) include applications in standing, walking, hand grasp, bladder and bowel function, respiratory assist, and electroejaculation. Several neuroprosthetic devices have gone through regulatory review and have reached the clinical world.
  • 10 - Environmental control and assistive devices
    pp 136-146
  • View abstract

    Summary

    This chapter focuses on the use of assistive technology (AT) to address residual deficits resultant from a traumatic brain injury (TBI). It specifically discusses the use of AT for neuromotor impairments, cognitive impairments and sensory-perceptual impairments. Prior to recommending assistive devices, a thorough assessment of the individual should be performed. The assessment must consider the individual's physical deficits and strengths, cognitive status, sensory status, functional status, environment, the tasks the person performs or would like to participate in, caregivers, and others living in the person's environment. Common motor deficits resultant from neurologic conditions include impairments in balance, gait, gross and fine motor coordination, and unilateral weakness or paralysis. Finally, the chapter covers AT by categories of activities of daily living (ADL). ADL includes bathing, dressing, grooming, toileting, eating/drinking, walking/mobility, etc.
  • 11 - Wheelchair design and seating technology
    pp 147-164
  • View abstract

    Summary

    Wheelchair and seating biomechanics research includes studies to prevent secondary conditions due to wheelchair and seating use, and to reduce the incidence of accidental injuries. Upper extremity models have been created in order to determine motion as well as net joint forces and moments. It has been shown that wheelchair pushrim forces are related to nerve conduction studies (NCS) variables. A pushrim activated power assisted wheelchair (PAPAW) uses motors and batteries to augment the power applied by the users to one or both pushrims during propulsion or braking. Powered wheelchairs can be grouped into several classes or categories. A convenient grouping by intended use is primarily indoor, both indoor/outdoor, and active indoor/outdoor. In response to the needs of clinicians with specialized knowledge of and experience with assistive technology (AT), the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) developed a credentialing program in AT.
  • 12 - Rehabilitation robotics, orthotics, and prosthetics
    pp 165-181
  • View abstract

    Summary

    One overarching goal drives the research and development activities: to revolutionize rehabilitation medicine with mechatronics, robotics, and information technologies that can assist movement, enhance treatment and quantify outcomes. This chapter presents three fronts of this revolution: rehabilitation robotics, orthotics, and prosthetics. It also presents the authors own results to delineate the potential of the technology and future directions for rehabilitation robotics. To date, the authors have deployed three distinct robot modules in collaborating clinical institutions for shoulder and elbow, wrist, and spatial movements. Orthotics plays an important role in the rehabilitation of patients with motor impairments. Despite advances in technology, progress in the development of effective upper-limb amputation prostheses has been modest. Providing an amputee with the ability to adjust impedance yields superior performance, and helps improving upper-limb prostheses. In the advancement of prosthetic systems, one feels that distributed sensory architectures are research areas of critical importance.
  • 13 - Virtual reality in neurorehabilitation
    pp 182-197
  • View abstract

    Summary

    This chapter provides an overview of applications of virtual reality (VR) to rehabilitation. A key concept related to VR is immersion. Immersion relates to the extent to which the VR system succeeds in delivering an environment which refocuses a user's sensations from the real world to a virtual world. Virtual environments are usually experienced with the aid of special hardware and software for input and output. Visual information is commonly displayed by head mounted displays (HMDs), projection systems or flat screens of varying size. VR applications in rehabilitation are expanding at a rapid pace and a large variety of platforms and programs are currently being used and developed. It has been used as a medium for the assessment and rehabilitation of cognitive processes. The ultimate goal of VR-based intervention is to enable clients to become more able to participate in their own real environments in an independent manner.
  • 14 - Communication devices
    pp 198-214
  • View abstract

    Summary

    Advances in the technology of communication devices and communication training have greatly expanded the proportion of affected individuals who can reacquire the ability to communicate. The growing body of knowledge and clinical experience related to supporting communication by means of assistive devices and techniques is known as augmentative and alternative communication (AAC) or augmentative communication. There are many kinds of actions that can be sensed and converted into the equivalent of a switch closure or a computer keystroke. Just as devices can be categorized, device-users are often considered in terms of the disability that is at the root of their need for communication support. This chapter points out considerations that are often of special concern for particular disability groups. Communication devices could contribute considerably more, and may do so in the near future, in order to enable the citizens to express their full cognitive, social and emotional potential.
  • 15 - Chronic pain
    pp 219-230
  • View abstract

    Summary

    This chapter reviews the evidence on plastic changes along the neuraxis and their relationship to pain in humans. It delineates treatment approaches that are designed less towards analgesia but more towards reversing maladaptive plasticity with the hypothesis that this would consequently also reduce chronic pain and extinguish pain memories. Implicit pain memories can be established and altered by learning processes such as habituation and sensitization, operant and classical conditioning or priming. The chapter suggests that the alteration of somatosensory pain memories might be an influential method to reduce both chronic musculoskeletal and neuropathic pain. Cortical plasticity related to chronic pain can be modified by behavioral interventions that provide feedback to the brain areas that were altered by somatosensory pain memories or by pharmacologic agents that prevent or reverse maladaptive memory formation. Future research needs to focus on emotional changes that contribute to and interact with the sensory and motor changes.
  • 16 - Loss of somatic sensation
    pp 231-247
  • View abstract

    Summary

    This chapter focuses on the loss of somatic sensations, treatments currently available to address this problem, and potential application of theories of perceptual learning and neural plasticity. Loss of somatic sensations can be sustained due to damage at various levels of the sensory system, for example from receptors to peripheral nerves, spinal cord, brainstem and cerebral cortex. The potential for recovery of somatosensory abilities are demonstrated, following lesions to peripheral and central nervous systems under both spontaneous and training-induced recovery conditions. Neurorehabilitation needs to be founded on a rigorous basic and clinical science platform and include cure in its mission. Review of theories of perceptual learning and the conditions under which neural plastic changes occur suggests a number of principles that have potential application in retraining somatosensations following peripheral nervous system (PNS) or central nervous system (CNS) injury.
  • 17 - Management of spasticity
    pp 248-264
  • View abstract

    Summary

    This chapter reviews the pathophysiology of spasticity, and outlines the rationale for treatment and the development of treatment goals. Lesions of the brain and spinal cord that interfere with the descending motor pathways often result in spasticity. A number of neurotransmitters are involved in the sensory and motor pathways that regulate muscle tone. Spasticity can be evaluated at bedside during the physical examination. It can be more formally assessed using quantitative scales and laboratory measures. Orthotic devices are considered in the management of spasticity, to reduce tone, improve range of motion, prevent contractures, and reduce pain. Treatment for spasticity is generally initiated when the increase in muscle tone interferes with functional activities. The chapter discusses the pharmacologic and surgical management strategies. For focal spasticity, treatment with botulinum toxin or nerve blocks may of benefit. For severe refractory cases of spasticity neurosurgical procedures can be considered.
  • 18 - Arm and hand weakness
    pp 265-282
  • View abstract

    Summary

    This chapter identifies and describes weakness of the upper extremity (UE) through exploration of impairment in movements following cerebral injury. Weakness can result from inadequate strength caused by limitations in force production. Weakness is recognized as a major impairment causing disability and thus a primary obstacle to stroke recovery. Prognosis of UE motor recovery after upper motor neuron (UMN) lesions remains difficult and uncertain. In light of reduced health care reimbursement, development of accurate prognostic indicators is essential for the delivery of cost-efficient rehabilitation services and to guide clinicians in appropriate allocation of patients' resources. Future clinical outcome research studies should evaluate the degree to which the UE treatment intervention that affects weakness also affects functional outcomes as well as family functioning and quality of life. This constellation of data will inevitably lend greater insight into the role and value of UE strengthening in neurorehabilitation.
  • 19 - Gait disorders and rehabilitation
    pp 283-297
  • View abstract

    Summary

    This chapter focuses on the role of neuronal mechanisms underlying gait disorders and the therapeutic consequences. Locomotion is a subconciously performed everyday movement with a high reproducibility. Leg muscle activation during locomotion is produced by spinal neuronal circuits within the spinal cord, the spinal pattern generator. Pathophysiologically, an impaired neuronal control of gait associated with rigid and poorly modulated motor performance represents a major deficit of Parkinson's disease. In patients with Parkinson's disease several studies on gait indicate an impaired programming. Spasticity produces numerous physical signs such as exaggerated reflexes, clonus, and muscle hypertonia. A considerable degree of locomotor recovery in mammals with a spinal cord injury (SCI) can be attributed to a reorganization of spared neural pathways. For future application in the rehabilitation field, gait analysis may help to select the most effective pharmacological and physiotherapeutical approaches.

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