DR. NIRMAL SURYA, MD,DNB, FIAN

DR. NIRMAL SURYA, MD,DNB, FIAN

President, Indian Federation of NeurorehabilitationPresident Elect, AOSNR

President Elect, Indian Academy of NeurologyMember at Large, Presidium, WFNRChair, ICHA Telemedicine Academy

EC Member, ISA(2018-2021)President, Xth WCNR2018

Chair, Developing World Forum, WFNRRVP, South Asia, WFNR

Movement disorder: Term used for Physical sign of abnormal movement in absence of weakness The syndrome that causes such motor abnormalities

Movement disorders disrupt motor function by Abnormal, involuntary, unwanted movements (hyperkinetic movement

disorders) Curtailing [restricting] the amount of normal free flowing, fluid

movement (hypokinetic movement disorders) hypokinetic movement disorders are accompanied by abnormal states

of increased muscle tone Pathology is in basal ganglia

Insufficient movement

Akinetic, hypokinetic or bradykinetic

syndromes

Too much movement

Jerky movements

• Myoclonus (including excessive startle)

• Chorea (including ballism)• Tic disorders

Non-jerky movements

• Dystonia (including athetosis)• Tremor

Parkinson’sdisease

Abdo, W. F. et al. Nat. Rev. Neurol. 6, 29–37 (2010); doi:10.1038/nrneurol.2009.196

Managing Problem associated with Movement disorder like Gait,posture control,fall, transfer,function and general therapy

Exercises Movement strategy Training

Chair, Developing World Forum, WFNRRVP, South Asia, WFNR

hands-on impairment-level intervention to improve body level performance

Provision of information and education –to facilitate informedchoice and optimize self management ability

Managing the environment-eg: adapting facalities, to reduceeffort or risk, or to remove the need to undertake a problem task together

Skill level intervention

Knowledge level intervention

Attitude level intervention

Assess/observe/monitor/measure changes Enhance/ maintain/restore movement/mobility/activity

level/physical activity/participation in social roles Promote independence/slf care/adaptation to new social roles Promote optimal Medicational Management Prevent secondary complications like falls, pain,skin lesions etc. Optimize bladder and bowel function Facilitate coping and care giver Provide palliative care if required Collect evidence on outcomes and effectiveness of care

Dysarthria: hypokinetic ( predominantly seen with PD) Hyperkinetic a) slow like dystonia b) fast like choreaAssesment: word/sentences/paragraph/picture description etcTreatment : hypokinetic or hyperkinetic

role is limited in chorea/dystoniaAAC : Alternate and Augmentative communication RoleCognitive - Linguistic disorders: Assesment / Managementcompensatory and behavioural approaches/ functional training

Cough/choaking/wet and gurgly voice after food/ sialorrhea or excessive drooling and weight loss

Assesment of swallowing disorder; bedside/ FEES Management: compensatory strategies: consistency of fluid and

food/ Bolous modification/ portion/postures and maneuvers(chin tuck or down)

Supraglottic swallow/ effortful swallow/Mendelssohn maneuver)

Speed of processing and motor prepertaion(HD and dystonia ) Temporal Processing Internal V/Sexternal control of attention and action Automatic V/S controlled performance of action Concurrent performance: doing two thing at once Inhibition of prepotent responses and response selection under

conflict Procedural and skill learning

Dystonia - a syndrome describing a special form of muscle hyperactivity characterised by

Sustained or intermittent muscle contractions causing

Abnormal, often repetitive movements, postures, or both

Dystonic movements are typically patterned, twisting, and may be tremulous

Dystonic muscle hyperactivity is often painful

Rehabilitation of Movement Disorders 2016 67-81

Dystonia is a movement disorder characterized by abnormal musclecontractions that can be worsened by stress.

The result is co-contraction of inappropriatemuscles and overflow of electromyographic activity, alongwith marked difficulty in switching the component movements of a complex task.

Physiotherapy

Occupational therapy

Speech therapy

Psychotherapy

Use of orthoses

Counselling of the patient and

their family

The combination of methods applied and their frequency and intensity depend on the severity of the patient’s individual dystonia


Botulinum Toxin(BT)therapy is the treatment of choice for cervical dystonia

DBS is an alternative

Anti-dystonic drugs and adjuvant drugs may be used at the end of the BT treatment cycle

When BT therapy is used, physiotherapy is necessary in most patients

Behavioural therapy is mainly based on electromyographic feedback techniques.


BT therapy is the treatment of choice for Blepharospasm

Levator suspension operation connecting the upper eyelid to the frontalis muscle via a Goretex® string is helpful

Deep brain stimulation (DBS) is principally effective in blepharospasm


Laryngeal dystonia (spasmodic dysphonia) is an extremely rewarding indication for BT therapy

Rehabilitation of spasmodic dysphonia is usually applied as speech therapy

• Stress• Voice overuse • Unfavourable situations including talking over the phone and noisy places

General recommendations include avoidance of


For writer’s cramp and musician’s cramps BT is the treatment of choice

The concept of re-learning normal movements by improving independence and the precision of individual finger and wrist movements

Occupational therapy is even more widely used and employs a large number of different strategies

• Biofeedback techniques • Habit reversal training • Constraint-induced motion therapy or sensory motor retuning• General training exercises • Supinator writing practice

Behavioural therapies include


Current evidence on feasibility, validity and cost effectiveness of Rehabilitation in Dystonia is limited

Large variety of interventions described but not many testedin controlled manner

Methodological shortcomings of many published study Complexcity warrant inter-professional approach to optimize

QOL and reduce impairment and disability

Rehabilitation of Chorea

Chorea is a movement disorder that is characterized byirregular, rapid, flowing, nonstereotyped and random involuntary movements. It maybe a part of Huntington’s disease which is characterized by triad of motor, cognitive and emotional disorders. Relatively early involvement of cognition makes rehabilitation of HD a challenge. Therapeutic programs that require motivation and skill learning are not effective.

Rehabilitation strategies include exercises to improve strength, aerobic fitness, flexibility, coordination, postural stability and efficiency of breathing and coughing. Cognitive retraining can be started early in the rehabilitation. Therapy that is individualised but conducted in a group setting has been shown to be effective. Unlike other gait disorders, prescription of gait aids may not useful because of difficulty in performing dual tasks.

PSYC4080 6.0D Movement Disorders 26

Hereditary - dominant gene on Chromosome 4 Causes a degeneration of the caudate nucleus and putamen

(basil ganglia) GABA and Ach neuron loss Uncontrollable movements, usually jerky limbs Progressive, leading to death (due to complications from

immobility) Symptoms start in 30s-40s No Medical treatment for the disorder Rehabilitation as support therapy to prevent complications

Presenter

Presentation Notes

Striatum = caudate and putamen

Rehabilitation in Ataxia

Improvement of Proprioception Propioceptive neuromuscular facilitation Rhythmic stabilisation Slow reversal technique Resistance exercises

Gait exercises on soft ,hard ,inclined, uneven surfaces Plyometric exercises Minitrampoline exercises Feldenkraise techniques Alexander techniques

Mat activity of PNF Static stabilisation Dynamic stabilisation Bridging Weight shifting Tandem gait ,Forward walking ,backward walking Soldiers gait ,Stand alone marching Tai chi ,Yoga Coordination Dynamic therapy

StaticDynamic

Intensity=sensory or time

Bridging Rolling Prone on all four limbs

Kneel walking Half kneeling Standing

Regular Exercises on Mat

Sitting on vestibular ball

Prone on vestibular ball

When people present with the early signs and symptoms of ataxia, they are likely to engage in unsupervised activities in an attempt to minimize their symptoms.

Guidance of a skilled professional is key at the beginning of any program to incorporate activities that are suitable for these patients.

Physical therapy should not be discontinued in advanced stages of disease in dependent, bedridden people

Passive/assisted mobilization and correct positioning are essential at these stages to maintain the same level of residual activity, prevent pain and bedsores, and improve well-being.


Balance training should be functional, i.e., people should practice functions in the performance of daily tasks that

require balance and proper posture.

In addition to balance and coordination exercises, muscle strength and stretching exercises should be performed in

every position

Promote stability by using different positions and while progressing from one position to another

Keep the best posture for as long as the patient can


A home practice program should incorporate other physical activities such as sport activities to train

components of basic skills in patients with ataxia.

Exercises should be practiced consciously at first, and in later stages should be followed by automatic exercise

activities

Strength training should use body weight exercises

As patients have to maintain an unbalanced position to train balance reactions, these exercises should be performed safely and progress depending on their

symptoms

“Disturbances in the sensory input to the cerebellum” Tests of proprioception- Joint sense, passivemovement “The corrective effects of the Visual system”Classical Sensory Ataxic GaitRomberg’s sign Loss of tendon reflexes Features of Peripheral neuropathy

Orthotics in Patients with dystonia meets the objective of correcting the position of the hand in order to facilitate the function and prevent deformity.

Because the movement is generated for a functional objective based on a pattern or muscle string, when manufacturing the orthotic the therapist should consider the position and angulations of the wrist in order to facilitate the initiation of the chain movement (neutral or minimal flexion).

Chairs should provide sufficient stability and symmetry in the pelvis.

The seat model depends on how much axial support needed. They provide containment of the pelvis and trunk, facilitating

the use of upper extremities in different planes, without the need for proximal fixation in the extremities.

For wheelchair and sitting it is a priority to give abduction and flexion at an angle less than 90 degrees to the pelvis to make sure the center of gravity is back and avoid the extensor pattern

Recent Advances

Conventional gait training does not restore a normal gait pattern in the majority of stroke patients

Robotic devices are increasingly accepted among many researchers and clinicians and are being used in rehabilitation of physical impairments in both the upper and lower limbs

Belda-Lois et al. Journal of NeuroEngineering and Rehabilitation 2011, 8:66

Advantages

Safe, intensive and task-oriented

rehabilitation

Precisely controllable assistance or

resistance during

movements

Good repeatability

Objective and quantifiable measures of

subject performance

Increased training

motivation through the use

of interactive (bio)feedback.

(a) The GyroGlove™ is worn to reduce hand tremor when the patient requires accurate hand movements (b) LiftLabs™ tremor cancelling spoon, which

improves accuracy by opposing tremor caused by disease

Greydon Gilmore and Mandar Jog. Future Perspectives: Assessment Tools and Rehabilitation in the New Age. Movement Disorders Rehabilitation, DOI 10.1007/978-3-319-46062-8_10

Brain-Computer Interface (BCI) systems record, decode, and translate some measurable neurophysiological signal into an effector action or behavior

BCIs establish a direct link between a brain and a computer without any use of peripheral nerves or muscles

The enable enabling communication and control without any motor output by the user


Functional near infrared spectroscopy (fNIRS) is a noninvasive psycho-physiological technique

It utilizes light in the near infrared range (700 to 1000 nm) to determine cerebral oxygenation, blood flow, and metabolic status of localized regions of the brain

fNIRS uses multiple pairs or channels of light sources and light detectors operating at two or more discrete wavelengths.


ADVANTAGES

Greater consistency of therapy

Home use

Never tiring out

Highly motivating

Optimized patient support

Precise measurements & assessments

Labor and therapy costs saving

ISSUES

Less flexible than therapist

Risk of obsolescence

Costly

Space consuming


It is reasonable to expect a better insight in the understanding of the rehabilitative process if top-down approaches are considered.

Regarding neurophysiological and motor learning Techniques, there is insufficient evidence to state that one approach is more effective than the other

There is moderate evidence of improvement in walking and motor recovery using robotic devices including systems for BWS when compared to conventional therapy

The combination of different rehabilitation strategies seems to be more effective than over-ground training alone


Rehabilitation in Movement disorder is challenging Though there are definite evidence available in diseases like

PD and Ataxia, we still searching for ideal plan for Chorea and Dystonia

Psychological support in above is crtitical besides medical therapy

Rehabilitation need to continue even post surgery in Dystonia MDT could make a difference in QOL with these syndrome

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DR. NIRMAL SURYA, MD,DNB, FIAN

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