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Year : 2021  |  Volume : 15  |  Issue : 3  |  Page : 77-84

AOCNR Scientific Deliberations

Date of Web Publication16-Mar-2022

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How to cite this article:
. AOCNR Scientific Deliberations. Physiother - J Indian Assoc Physiother 2021;15, Suppl S1:77-84

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. AOCNR Scientific Deliberations. Physiother - J Indian Assoc Physiother [serial online] 2021 [cited 2023 Jun 3];15, Suppl S1:77-84. Available from: https://www.pjiap.org/text.asp?2021/15/3/77/339729

  Experience of COVID 19 and Neurorehabilitation Symposium Top

  Viewpoint from Brunei Top

Abang Muhammad Fahmy Hepnie

Experience of Covid-19 and Neurorehabilitation Symposium 7th August 2021 Summary for Viewpoint from Brunei: Brunei is a country situated in the north western part of the island of Borneo with a population of 459 400. It recorded its first positive case (imported from overseas travel) on 9th March 2020 and as of 1st August 2021 has detected 338 positive cases. However, the last local case of Covid-19 was reported on 6th May 2020, 452 days ago. Brunei has been relatively successful in managing the Covid-19 pandemic in the country. This has been achieved Brunei's extensive testing for Covid-19 and synergistic whole nation approach in tackling the situation. Medical rehabilitation services in Brunei were significantly reduced from March 2020 until July 2020 when social distancing measures and new management directives were implemented in the country. Tele-rehabilitation substituted face to face sessions. Due to social distancing, home rehabilitation programs were suspended. Hydrotherapy programs and group programs were also suspended. A significant number of rehabilitation staff in the Ministry of Health was also redeployed to help with the national response to Covid-19 pandemic. Locally, positive Covid-19 patients are treated in the National Isolation Centre, where strict infection control guidelines, including wearing full personal protective equipment (PPE), are mandatory for the staff. Most of the positive Covid-19 patients treated in the National Isolation Centre did not require rehabilitation and were not referred to rehabilitation and allied health professional input. The few referrals to physiotherapy were given input via telerehabilitation. Rehabilitation services returned to normal service after July 2020.

  Symposium on IT and Neurorehabilitation Top

  Manastik - Connecting technology to neurorehabilitation Top

Akshay Sancheti

Entrepreneur, Manastik - 411 051, India

In “Manastik – Connecting technology to Neuro rehabilitation”, we talk about how cutting edge technology is being leveraged to develop simple, accessible and iordable online tools to aid Neuro-Rehabilitaiton. Manastik is a platform to connect technology with Neurology and Neuro rehabilitation. They partner with Neurologists, Physiotherapist, Speech Language Pathologists, among others, to develop effective and online Neuro-rehabilitation tools. In this talk, they demonstrate some of the tools Manastik has built and showcase how technology can be used to overcome fundamental healthcare challenges like iordability, accessibility and inclusivity. With these innovative applications we can truly bring Neuro rehabilitation from Hospital to Home.

  AOCNR 2021 Top

  Rehabilitation care continuum for stroke survivors: Beyond hospital to the community Top

Seng Wai Ping, Alfred

Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore


After suffering a stroke, a patient transits from acute hospitalisation to several rehab destinations including inpatient rehabilitation wards, residential-based services, centre-based services and home-based care. This is dependent on various factors such as stroke severity and the availability of a carer. Implementing integrated care pathways improves triage workflows and facilitate the passage of stroke patients across the stroke rehab continuum. In Singapore, a single agency (Agency for Integrated Care) coordinates the delivery of care services provided by many community care partners, and improves the rates of successful placement and matching.

Early Supported Discharge brings contextualised rehab services to the patient's own home and promotes re-integration to home and the community. The multidisciplinary team provides education on home exercises, trains the use of powered mobility devices, performs counselling, as well as accompany the stroke survivor on community outings.

Multiple organisations run return-to-work programmes, including sheltered workshops that provide vocational training until stroke survivors possess competencies for open employment. Being able to resume driving improves quality of life, so many stroke survivors undergo the Driving Assessment and Rehabilitation Programme. Passing both the off-road and on-road assessments will allow them to drive safely on the roads.

With the advent of telemedicine in the Covid-19 pandemic, creative ways of delivering rehabilitation remotely include telerehabilitation and smartphone applications. Robotics and assistive technology have also been introduced to many centre-based services to supplement conventional therapy and are kept iordable. Regular virtual support group meetings and workshops are organised by the Singapore National Stroke Association, which is the national support group for stroke survivors and caregivers.

As the mortality rate of stroke decreases with advancements in medical treatment, the number of stroke survivors living with disabilities in the community increases. As such, the need for sustainable, effective and iordable rehabilitation options beyond the acute hospital stay remains ever so important.

  Neurorehabilitation in pediatric epilepsy Top

Anaita Udwadia-Hegde (7th August 2021)

Consultant Pediatric Neurology, SRCC Narayan Health Care Children's Hospital

International league against epilepsy (ILAE) defines epilepsy as the occurrence of two unprovoked (or reflex) seizures occurring more than 24 hours apart or one unprovoked (reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures. The spectrum of clinical manifestations not only includes the disorders and co-morbidities associated with the disease, but also the side effects of the anti-seizure medicines. Significant brain growth in initial years of life as well as vulnerability and neuroplasticity of developing brain makes pediatric epilepsy different from adult epilepsy, which is the primary basis for neuro rehabilitation. The epilepsy model suggests that there is always a latent period between the insult and the occurrence of first seizure and neuro rehabilitation initiated in this time provides the best results.

The major contribution to pediatric epilepsy is made by the disorders including secondary epilepsy associated with cerebral palsy and few of the primary epilepsies. Less common ones include genetic syndromes, neuro metabolic and neuro development disorders. Epilepsy not only cause physical and mental problems, but also leads to psycho-social impairment. The damage can be attributed to seizures as well as to the side effects of the treatment and family and social issues. Intellectual disability, autism spectrum disorders, hyperactivity, behavioral problems and academic concerns are important associations of epilepsy. Epilepsy can also lead to a large number of co-morbidities including sleep problems, dietary issues, recurrent chest infections, anxiety and depression. Therefore, along with effective seizure control, the purpose of neuro rehabilitation is to minimize cognitive deficits and behavioral issues, manage psychosocial obstacles and treatment of co-morbidities.

Neuro rehabilitation team should include pediatric neurologist, pediatric neuro surgeon, psychologist and counsellor, physical medicine and rehabilitation team (physiotherapist, occupational therapist, speech therapist). The basic principles of neuro rehabilitation are.

  1. Understanding of the physical, emotional, cognitive, and social consequences of a child's injury
  2. Emphasis on the strategies designed for functional improvement
  3. Assessments must be guided by a detailed understanding of normal developmental milestones of the child as sequential goals
  4. Family-centered care and their participation in the rehabilitation process and therapy programs
  5. Initiation of intervention and rehabilitation as soon as possible, once the child is medically stable to limit maladaptive movement patterns and to minimize the complications.

Cognitive dysfunction may be associated with refractory seizures, epileptic encephalopathy or side effects of anti-seizure medications. It interferes with academic and professional performance of the child. Behavior issues and hyperactivity is more commonly seen with frontal lobe epilepsy, while temporal lobe epilepsies are known to be associated with memory, learning and cognitive deficits. Presence of psychiatric symptoms can worsen not only cognitive functions but can also exaggerate the cognitive side effects of anti-epileptic medications. A detailed neuropsychological evaluation should be done in all children with epilepsy to evaluate new onset or existing behavioral issues, learning disabilities and cognitive problems, which should always be followed by initiation of behavior therapy and pharmacotherapy. Apart from behavior, cognitive and psychiatric problems, an important aspect of neuro rehabilitation is management of psycho-social issues. The most common witnessed psycho-social issues are parental concerns (anxiety, neglect, overprotection), misconceptions about epilepsy, lack of knowledge in school environment and social stigma. Caregivers, teachers and school friends should be counseled and educated about the epilepsy to decrease the impact of psychosocial issues.

Epilepsy surgery has emerged as a promising option in cases of medically refractory epilepsies with well localized seizure focus. It is known that delay in considering surgical option may sometimes cause worsening of cognitive and behavioral issues. But, epilepsy surgery itself may associated with post-surgical cognitive and memory deficits. A detailed preoperative psychosocial, neuropsychological, language and psychiatric as well as motor assessments should be considered a mandatory part of the pre-surgical work-up.

To conclude, keeping in mind the neuroplasticity and vulnerability of developing brain, management of paediatric epilepsy is very different from adults. The associated conditions and comorbidities can be more disabling than the epilepsy. Thus, the holistic treatment approach is not only seizure control, but also to give the child a normal age-appropriate life. The goals of Neuro rehabilitation are to improve functional abilities, to create positive environment, to minimize the complications and side effects and to provide education, counselling and therapy to the child and family. Early identification & intervention are the key factors to good outcomes.

  New directions in aphasia rehabilitation Top

Andrea Marini

University of Udine, Udine, Italy

This abstract briefly outlines the contents of the lecture on the “New directions in aphasia rehabilitation” at the Asia Oceanian Congress on Neuro Rehabilitation 2021. Aphasia is an acquired language disorder that may occur in people suffering from stroke (Basso et al., 2013; Rhode et al., 2013), Traumatic Brain Injury (TBI; e.g., Heilman et al., 1971) or other disorders (e.g., neurodegenerative processes such as in Primary Progressive Aphasia; Marshall et al., 2018). Its characteristics vary depending on a range of factors. Overall, in persons with aphasia (PWA) microlinguistic (i.e., phonological, lexical and grammatical) skills are usually iected with heterogeneous symptoms depending on illness severity (mild, moderate, severe) and iected linguistic modalities (i.e., production, comprehension and/or repetition). Importantly, microlinguistic difficulties may have also effects on macrolinguistic (i.e., pragmatic and discourse level) processing (e.g., Andreetta et al., 2012; Andreetta and Marini, 2015).

In the acute phase within the first three months post onset an initial spontaneous recovery can be observed (Picano et al., 2021). Interestingly, there is also evidence suggesting that therapies that focus on syntactic skills and on the ability to produce informative messages may enhance such recovery already in the early post onset period in non-fluent PWA (e.g., Marini et al., 2007). Further linguistic improvements can occur after behavioral training also in the chronic phase (Fama et al., 2014).

A crucial predictor for positive language outcomes is the intensity of the linguistic training (5 to 10 hours per week; e.g., Bhogal et al., 2003). For example, Marini et al. (2016) observed in a bilingual patient with extensive loss of the left hemisphere due to severe traumatic brain injury a remarkable language recovery (in both languages) after an intensive training (focused only on one of these languages, i.e., Italian) twice a week for 5 years with a reorganization of his linguistic network in the right hemisphere. Unfortunately, a number of reasons (e.g., the limited economic resources of the national health systems, the high costs of private health care services) do not allow PWA to have access to the recommended amount of training. For these reasons, to enhance the efficacy of the rehabilitation process over the past 20 years innovative rehabilitation methods have been developed. These may act either as a substitute or an adjunct to traditional approaches. Two examples of such innovations include the Virtual Reality (VR) and the Transcranial Direct Current Stimulation (tDCS) approach (Picano et al., 2021).

VR applications are computer-generated simulations of 3D environments that allow to perform therapies aimed at enhancing functional communication in ecological contexts (Brady et al., 2016). The development of VR applications for linguistic and communicative rehabilitation in PWA is still at an early stage (Grechuta et al., 2019; Marshall et al., 2016). Nonetheless, growing evidence supports its efficacy for the rehabilitation of language in PWA (e.g., Giachero et al., 2020). The use of virtual everyday contexts enhances the ecological validity of treatment protocols as the semi-immersive interaction encourages language practice in realistic communication contexts. Furthermore, it should also be noted that the inclusion of a virtual therapist does not require the presence of a clinician. Therefore, the PWA may practice it every time (s) he wants to (even several hours a day, implementing an intensive training) reducing his/her feeling of loneliness and social isolation (Thompson et al., 2010; Cherney and van Vuuren, 2012).

Recent advancements in neurorehabilitation take into account the mechanisms underlying cerebral reorganization (Picano et al., 2021; Taub et al., 2002).Transcranial Direct Current Stimulation (tDCS) is a non-invasive adjunctive therapy for neurological disorders (Fregni et al., 2020; Lefaucheur et al., 2017) that modulates cortical excitability by inducing a slight electrical current (1-2 mA) through surface electrodes applied over the scalp (Monte-Silva et al., 2013; Nitsche and Paulus, 2011). Also in this case, increasing evidence suggests its utility as an effective supplementary treatment in persons with chronic aphasia (Marangolo, 2020). For example, in Marangolo et al. (2013) a conversational therapy paired with anodic transcranial Direct Current Stimulation of the left Inferior Frontal Gyrus significantly increased the linguistic production skills of a cohort of 12 persons with chronic non-fluent aphasia who had not benefited from a traditional therapy.

In conclusion, language rehabilitation in PWA is the target of growing interest among aphasiologists. This renewed interest has been prompted, among other things, by the development of relatively new neuromodulation techniques that are promising in enhancing the efficacy of the rehabilitation process (i.e., tDCS) and new technologies that allow PWA to be immersed in virtual communicative scenarios that can be used not only in the clinical setting but even at home. This is a critical step to provide such patients with the possibility to be engaged in intensive programs.


  1. Andreetta A, Marini A. The effect of lexical deficits on narrative disturbances in fluent aphasia. Aphasiology 2015;29:705-23.
  2. Andreetta S, Cantagallo A, Marini A. Narrative discourse in anomic aphasia. Neuropsychologia 2012;50:1787-93.
  3. Basso A, Forbes M, Boller F. Rehabilitation of aphasia. In: Handbook of Clinical Neurology. Milan, Italy: Elsevier; 2013.
  4. Bhogal SK, Teasell R, Speechley M. Intensity of aphasia therapy, impact on recovery. Stroke 2003;34:987-93.
  5. Brady MC, Kelly H, Godwin J, Enderby P, Campbell P. Speech and language therapy for aphasia following stroke. Cochrane Database Syst Rev 2016;CD000425.
  6. Cherney LR, van Vuuren S. Telerehabilitation, virtual therapists, and acquired neurologic speech and language disorders. Semin Speech Lang 2012;33:243-57.
  7. Fama ME, Turkeltaub PE. Treatment of poststroke aphasia: Current practice and new directions. Semin Neurol 2014;34:504-13.
  8. Fregni F, El-Hagrassy MM, Pacheco-Barrios K, Carvalho S, Leite J, Simis M, et al. Evidence-based guidelines and secondary meta-analysis for the use of transcranial direct current stimulation in neurological and psychiatric disorders. Int J Neuropsychopharmacol 2021;24:256-313.
  9. Giachero A, Calati M, Pia L, La Vista L, Molo M, Rugiero C, et al. Conversational therapy through semi-immersive virtual reality environments for language recovery and psychological well-being in post stroke aphasia. Behav Neurol 2020;2020:2846046.
  10. Grechuta K, Rubio Ballester B, Espín Munne R, Usabiaga Bernal T, Molina Hervás B, Mohr B, et al. Augmented dyadic therapy boosts recovery of language function in patients with nonfluent aphasia. Stroke 2019;50:1270-4.
  11. Heilman KM, Safran A, Geschwind N. Closed head trauma and aphasia. J Neurol Neurosurg Psychiatry 1971;34:265-9.
  12. Lefaucheur JP, Antal A, Ayache SS, Benninger DH, Brunelin J, Cogiamanian F, et al. Evidence-based guidelines on the therapeutic use of transcranial direct current stimulation (tDCS). Clin Neurophysiol 2017;128:56-92.
  13. Marangolo P, Fiori V, Calpagnano MA, Campana S, Razzano C, Caltagirone C, et al. tDCS over the left inferior frontal cortex improves speech production in aphasia. Front Hum Neurosci 2013;7:539.
  14. Marangolo P. The potential effects of transcranial direct current stimulation (tDCS) on language functioning: Combining neuromodulation and behavioral intervention in aphasia. Neurosci Lett 2020;719:133329.
  15. Marini A, Caltagirone C, Pasqualetti P, Carlomagno S. Patterns of language improvement in adults with non-chronic non-fluent aphasia after specific therapies. Aphasiology 2007;21:164-86.
  16. Marini A, Galetto V, Tatu K, Duca S, Geminiani G, Sacco K, et al. Recovering two languages with the right hemisphere. Brain Lang 2016;159:35-44.
  17. Marshall J, Booth T, Devane N, Galliers J, Greenwood H, Hilari K, et al. Evaluating the benefits of aphasia intervention delivered in virtual reality: Results of a quasi-randomised study. PLoS One 2016;11:e0160381.
  18. Marshall CR, Hardy CJ, Volkmer A, Russell LL, Bond RL, Fletcher PD, et al. Primary progressive aphasia: A clinical approach. J Neurol 2018;265:1474-90.
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  20. Nitsche MA, Paulus W. Transcranial direct current stimulation – Update 2011. Restor Neurol Neurosci 2011;29:463-92.
  21. Picano C, Quadrini A, Pisano F, Marangolo P. Adjunctive approaches to aphasia rehabilitation: A review on efficacy and safety. Brain Sci 2021;11:41.
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  23. Taub E, Uswatte G, Elbert T. New treatments in neurorehabilitation founded on basic research. Nat Rev Neurosci 2002;3:228-36.
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  Transcranial direct current stimulation as an augmentation for the attenuation of motor deficits in patients with stroke - A randomized controlled double-blinded study Top

Anupam Gupta, Ekta Franscina Pinto, Girish Baburao Kulkarni, Chittaranjan Andrade


Introduction: Most studies of transcranial direct current stimulation (tDCS) for motor deficits in patients with stroke administered few sessions of tDCS and with low current amplitude.

Methods: During 2015 to 2019, we randomized 60 inpatients with ischemic/hemorrhagic stroke and motor deficits to true or sham tDCS. Transcranial direct current stimulation was administered at 2- to 3-mA current strength, twice daily, 6 days a week, for 2 weeks; anode and cathode were placed over ipsilesional and contralesional motor cortices, respectively. All patients received individualized motor and cognitive rehabilitation. Motor outcomes were assessed 1 day before and 1 day after the tDCS course using the Fugl-Meyer Assessment, the Jebson-Taylor Hand Function Test, and the Barthel index (all coprimary outcomes). Mood and cognition were also assessed. Motor outcomes were compared between groups using age, baseline scores, and latency to treatment as covariates. The study was prospectively registered (CTRI/2017/01/007733).

Results: The mean age of the patients was 46.9 years. The sample was 73.3% male. Six patients did not complete the study. The covariates were significantly related to motor outcomes. Although all patients showed motor improvements, after adjusting for covariates, tDCS was not superior to sham treatment on any motor, mood, or cognitive outcome. Laterality of hemispheric lesion influenced spatial but not motor outcomes with tDCS. One true tDCS patient developed blistering under the anode and was withdrawn from the study; 3 more reported transient itching during sessions.

Conclusions: An intensive course of tDCS, as delivered in this study, does not improve motor, mood, and cognitive outcomes in ischemic/hemorrhagic stroke in patients undergoing individualized rehabilitation. The study provides important leads for directions for future research. Key Words: transcranial direct current stimulation, stroke, randomized controlled trial, motor outcomes mood outcomes, cognitive outcomes.

  Noninvasive neuromodutation for stroke recovery: State of the art Top

Areerat Suputtitada

Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand E-mail: [email protected], [email protected]

Non-invasive brain stimulation techniques, particularly transcranial Direct Current Stimulation (tDCS) and repetitive Transcranial Magnetic Stimulation (rTMS), are widely utilized to promote brain plasticity or remodeling following CNS injuries, which is important for sensory and motor recovery. Long-term potentiation (LTP) and long-term depression are the two primary physiologies of brain plasticity (LTD). Neuromodulation refers to neurophysiological techniques that can aid plasticity and modify cortical excitability. tDCS is becoming more popular due to its low cost, ease of administration after adequate training, portability, and lack of side effects. A small and continuous direct current delivered to the brain, according to the 10-20 system of cortical function, can either increase or inhibit cortical excitability. TMS modulates excitability levels and ongoing activity patterns by producing non-invasive electric currents in specific cortical areas, depending on stimulation parameters such as frequency, intensity, number of pulses, train duration, and inter-train intervals. The most recent data suggests that rTMS and tDCS have the ability to regulate brain cortical excitability with long-term effects, potentially enhancing neurorehabilitation for functional recovery and cognitive improvement.

Stroke is the leading cause of disability in individuals throughout the world and frequently results in motor dysfunction. Long-term impairment iects the majority of stroke patients, with up to 80% having chronic and incapacitating upper-limb dysfunction.[1],[2] Within the first 6 months following a stroke, 15–33 percent of patients recover, whereas 66 percent of patients do not.[1],[2] After that, recovery is limited.[3],[4],[5],[6],[7],[8],[9],[10],[11] Neuromuscular recruitment, timing, synchronization, and execution of critical motor activities are all iected by stroke.[12] Transcranial noninvasive brain stimulation (NBS) includes both repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS). TMS uses a rapidly changing magnetic field to induce currents and action potentials in underlying brain tissue, whereas tDCS involves the application of weak electrical currents to modulate neuronal membrane potential.

Transcranial magnetic stimulation (TMS) is a technique that includes stimulating neurons in the brain with alternating magnetic fields and monitoring the stimuli-induced responses with electromyography. The interdependence of electricity and magnetism has been known for over a century. Faraday, for example, established in 1831 that an alternating and quickly changing magnetic field generates electric currents in a nearby conductor. In this scenario, the current flows through a wire coil, creating a magnetic field perpendicular to the coil's plane. When a conducting material, such as the brain, is exposed to a magnetic field, an electric can be induced in it. The generated current will flow in a direction that is parallel but opposite to the current in the primary coil, which is the source of the magnetic field, but the actual currents will be highly influenced by the medium's anisotropic and inhomogeneous conductive qualities. As a result, the use of TMS implies electric stimulation without the usage of electrodes. The magnetic field acts as an intermediary between the coil and the induced electric currents in the brain in this model. When the coil is applied over the brain, the magnetic field undergoes little attenuation by extra cerebral tissues (scalp, cranial bone, meninges and cerebrospinal fluid) and induces an electrical field enough to depolarize superficial axons and to activate cortical neural networks. Several parameters influence the outcome of the stimulation, including the types and orientation of coils; the distance between the coil and the brain; the magnetic pulse waveform; and the intensity, frequency and pattern of stimulation. There are two treatment regimens as the followings; (1) the low-frequency rTMS, stimulates at frequencies lower than or equal to 5 Hz, which reduces neuronal excitability; (2) the high-frequency rTMS, stimulates at frequencies higher than or equal to 5 Hz., which increases cortical excitability.[13] A single stimulus of TMS with a specific intensity and orientation causes neuronal depolarization, followed by an action potential which produces an excitatory postsynaptic response of 1 ms, which is in turn followed by an inhibitory postsynaptic potential of 100 ms. TMS has a local effect, interrupting normal neural activity, increasing the refractory period, and regulating the discharge pattern.[12],[13] In clinical practice TMS could be used to tell the prognosis by mainly used to explore motor cortical areas and corticospinal tract conduction and connectivity. The effects of TMS on a specific area extend to other cortical and subcortical areas of both hemispheres; due to brain connectivity, the effects might even reach deep brain areas according to the diaschisis principle.[13],[14] Activation or inhibition of a specific area iects distant areas; the effects depend on whether the stimulus is excitatory or inhibitory.

At the neural network (mutual stimulation and inhibition of brain areas), synaptic, and/or molecular genetic (changes in gene expression, enzyme activity, and neuromediator synthesis) levels, there were a variety of possible processes. Endogenous dopamine and genetic polymorphisms have both been linked to variations in neurotransmitter concentrations following rTMS.[13],[14]

The effects of rTMS are highly dependent on the following factors: (1) stimulus strength and frequency; (2) acute and chronic treatment modes; (3) total number of pulses; (4) coil form and dimension; and (5) conscious state. The evidence in rodents suggests that rTMS has a wide range of neurobiochemical effects, including induction of early genes, changes in neurotransmitter release modulation, effects on glutamate AMPA receptor/NMDA receptor expression (influencing calcium ion dynamics), action on neuroendocrine systems, neuroprotective effects by reducing oxidative stress and inflammation, and a power boost. These molecular effects may alter neurons' intrinsic and extrinsic electrophysiological properties, as well as reprogram the expression of excitatory and inhibitory neurotransmitters and their cognate receptors, resulting in synaptic plasticity-related changes such as Long-term potentiation (LTP) and depression (LTD) phenomena.[13],[14],[15] bBoth HF-rTMS and LF-rTMS have been found to be safe and well-tolerated in clinical.[16]

The meta-analysis of 18 eligible trials were subjected, which revealed that NIBS had substantial beneficial benefits on functional balance and postural control after stroke. These therapy benefits were only significant in rTMS among patients with acute, subacute, and chronic stroke, according to the moderator-variable analyses, but tDCS had no meaningful therapeutic effects. A larger number of rTMS sessions was substantially related with better gains in functional balance and postural control poststroke, according to the meta-regression analysis.[17]

There were 42 studies that were found to be eligible, involving 1168 stroke patients. The summary effect size indicated that rTMS had positive effects on limb motor recovery and activities of daily living, and that motor-evoked potentials of the stimulated hemisphere differed according to stimulation frequency, with the high-frequency group) and the low-frequency group being the exception. Except for the sessions subgroup, no significant changes were seen across the stimulation parameter subgroups. Only ten of the articles included in the study reported minor pain following rTMS.[18]

Eight studies with 169 stroke patients were included in the meta-analysis. Pooled estimates demonstrated that rTMS significantly improved the body function of the lower limbs, lower limb activity, and motor-evoked potential. The subgroup analyses results also revealed that rTMS improved walking speed and lower limb scores on the Fugl-Meyer Assessment scale[19]

The study includes eight randomized controlled trials with a total of 841 stroke patients. The Fugl-Meyer Assessment; grip strength, and the Barthel Index demonstrated that rTMS is beneficial to patients with poststroke hemiplegia. There were just a few negative outcomes.[20]

When compared to other noninvasive neuromodulations, tDCS is becoming more popular for neurorehabilitation. It is a low-cost, simple-to-use, portable, and home-based design that is regarded the most cost-effective and high-compliance therapy. A small and continuous direct current given to the brain can either increase or inhibit cortical excitability. Depending on many circumstances, it has an impact for several hours after stimulation. Subthreshold depolarization occurs as a result of anodal stimulation, resulting in neuronal excitement. Two (or more) electrodes are placed to the scalp in clinical practice, with current flowing from the anodal to the cathodal electrode. Electrical currents are incapable of producing an action potential. The neuron operates at rest or during stimulation, relearning with a task in the meanwhile, and the stimulation time of day are all elements that impact neural activity. The intricate connections between the linked brain network and the stimulation region are responsible for the favorable therapeutic benefits of tDCS in different diseases.[13],[17]

Twenty-nine studies (351 patients and 152 healthy subjects) were reviewed. The result revealed that NIBS is associated with gains in fine motor performance in chronic stroke patients and healthy subjects. This supports the effects of NIBS on motor learning and encourages investigation to optimize their effects in clinical and research settings.[21]

tDCS appears to be a potential strategy for supporting recovery of lower limb function in both healthy people and stroke survivors, according to preliminary findings. Behavioral and physiological alterations in brain activity following tDCS have been seen in studies. tDCS is thought to induce neuroplasticity in the human brain without being intrusive by transiently modifying the resting membrane potential of cortical neurons. Much of the research into tDCS has so far focused on upper limb rehabilitation after stroke. Lower limb rehabilitation, on the other hand, is critical for recovering movement, balance, and independence and might benefit from tDCS as well.[22]

There is evidence that NIBS, when combined with effective rehabilitation therapy, can help with neuroplasticity rearrangement. The following are characteristics of a meaningful rehabilitation program: (1) the rehabilitation program must be meaningful in terms of skill learning. Non-skill and passive training, such as repeated voluntary and aided dorsiand plantarflexion motions, for example, showed no effect on cortical excitability, whereas motor skill training did. (2) A task-specific rehabilitation program is required. Those who were trained to stand did not walk well on a treadmill in the animal research with full spinal cord transections, whereas those who were trained to walk did not stand well. (3) Pathological movement should be avoided in collaboratively applied rehabilitation training to decrease the possibility of maladaptive reorganization.[13],[17]

In conclusion, Non-invasive stimulation techniques as rTMS and tDCS have the potentials to modulate brain cortical excitability with long lasting effects which promising enhance neurorehabilitation. More researches are upcoming in various indications and stimulation protocols.


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  Therapy guidelines across life span; Challenges and opportunities for rehabilitation in children with neuromuscular disorders Top

Asha Chitnis

Physiotherapist, Indian Academy of Cerebral Palsy, India

In Rehab, we have many options for current best practice therapeutic management reference for all health professional providing therapy. We in our clinical practice use the classification systems (GMFCS, MACS, CFCS, FMS, EDSC & VFCS) and ICF to assess a child with Neuromotor disability. The common question asked is 'will my child walk' Best scientific evidence comes out from the research & papers on Motor growth Curves.

  • This graph shows the observed and predicted GMFM-66 scores for children in GMFCS level I TO V.
  • The solid vertical line shows the age in years by which children are expected to reach 90% of their motor development potential.
  • Later there is slow and minimal improvement.

Rosenbaum et al. Prognosis of gross motor function in cerebral palsy: creation of motor developmental curves. JAMA 2002 Sep 18;288 (11): 1357-63 18;288 (11):1357-63.

The evolution of treatment approaches is as follows

Here we are in 2015, where have we beenwhere are we going Who will we travel with

  • what road will we take
  • where is our destination

The Neurophysiologic Approaches:

  • Neurodevelopmental Treatment (NDT) Berta & Karl Bobath
  • Proprioceptive Neuromuscular Stimulation (PNF) Herman Kabat, Margaret Knott & Dorothy Voss
  • Stages of Motor Recovery Signe Brunnstrom, a Swedish physical therapist
  • Sensory Integration
  • Margaret Rood, Occupational Therapist

  • Today in 2020

Understanding Neurorehabilitation 2020, we live in a time of great change as exciting new developments on the horizon in Neuroplasticity and other areas.Research is gradually improving our understanding of the underlying mechanisms iecting Cerebral Palsy and other Neuromuscular Disorders.

Our biggest challenge is finding the right dosage, timing & right intervention. (Documenting Physical Therapy Dose for Individuals With Cerebral Palsy: A Quality Improvement Initiative. - Bailes AF1, Strenk ML Pediatr Phys Ther. 2019 Jul; 31 (3):234-241)

Gaining insights into Neuroplasticity & Muscle plasticity; its role in rehabilitation is very important. Let us understand the definitions. Neuroplasticity can be defined as brain's ability to change, remodel and reorganize for purpose of better ability to adapt to new situations. (Demarin et al. 2014)

Muscle plasticity -Muscle Plasticity: Ability of skeletal muscle to alter its structural and functional properties in accordance with environmental conditions imposed on it (Bruton 2002).

Plasticity is driven by environmental change e.g., increased or decreased activity, genetic factors.

Let us understand can Therapy influence Neuroplasticty. What are the 10 principles of Neuroplasticity. How can we impact our Rehab

  • Use it or Lose it
  • Use it to improve it
  • Specificity: training for task, endurance, strength target different areas
  • Repetition
  • Intensity
  • Timing
  • Salience
  • Age
  • Transference/Interference

THERAPY –Discussion the best practice

The advent of newer technologies and new frontiers fetal rehab and early detection helps survival of a neonate at risk.” Early intervention “need of the hour.”

Early intervention is a system of coordinated services that promotes the child's age-appropriate growth and development and supports families during the critical early year

What are goals of Early intervention

The purpose of early intervention is to lessen the effects of the disability or delay.

Services are designed to identify and meet a child's needs in five developmental areas, including: physical development, cognitive development, communication, social or emotional development, and adaptive development.

Goals change from NICU to the first 2 years of life

The aims of intervention- Physiological stability, Attachment & Bonding, Increased weight gain, improved motor control, chest PT& improve oral feedings.

Where Do We Start. DO NO HARM !Adjusting your approach to fit the infant (APTA Practice Guidelines – Pediatric Section 1999, Sweeney at at AOTA 2000, 54, 641-641)

our understanding of The NICU environment, Providing Sensory Input in Preterm Infants how much is too much, too little or appropriate is challenge,& What do infant cues tells us is critically important.

Clinical practice guidelines for management/THERAPY GUIDELINES from 2-18 yrs need to be looked through many domains in rehab

Assessment -look at outcome measures – TIMP, Alberta Infant Motor Scale (AIMS)* Gross Motor Function Measure (GMFM), Functional Mobility Scale,) PEDI COPM AHA.HQRL helps us set SMART Goals

Basic principles of treatment to keep in mind while treating kids across the life span is –

Work for graded control Weight bearing through upper limbs, hips and knees work for OM Control,

Work for sensory systems sensory systems adapt to intrinsic and extrinsic stimuli and experience Sensory Systems continue to develop after birth Some are susceptible to “critical periods” e.g., vision. Almost Everything is Plastic!! Sensory System Plasticity

intensive intervention may be needed at various times to optimize outcomes. Engagement: Activities for motor learning need to be challenging enough but not too challenging

The Constantly Reorganizing Brain and Changing Musculoskeletal System - Musculoskeletal Plasticity is also very critical look for Indicative timelines like when do we do early Botox, casting &surgery & bony interventions

The clinical implications of Musculoskeletal Plasticity

  • Evidence suggests passive manual stretching does not alter progression of muscle contractures! (Rick liber)
  • Interventions that focus on changing pathology in muscle structures may provide new avenues for treatment.(Rick liber)
  • Some evidence suggests long term passive stretch may have positive effects on joint ROM but the mechanism is unclear and the effects on sarcomere length may be negative.
  • Active stretching and early development of active muscle contraction in functionally relevant tasks shows promise
  • Strengthening

As we move into Adolescence, TRANSITIONAL CARE is the next big thing we need a different team of professionals to take care of them. CP as a condition has survived [outgrown] pediatric rehabilitation. the adolescent of 2030 is the 3 yr old you are treating today. Prepare them for adolescence as we go.If, as we believe, successful participation has a positive influence on health and well being. How do we support adolescents to make the transition to adulthood and be independent, successful and contributing adults Our Goal at whatever age the client is Build Personal Skills and Capacity Reduce Environmental Barriers

Increase Environmental Support Adjust and reassess goals throughout, but remember, high expectation breeds higher results than minimal expectation.

Orthotic– We advice no dynamic bracing in the 1-2 yrs of life, or unless we do see mature gait.we do use SMO to allow for alignment we have many options to choose from the basic principles are.

Improve function and efficiency.

Improve joint biomechanics and alignment.

  • Prevent deformity.
  • Protection, after surgery.
  • The commonly used orthotics are AFO DYANMIC, SMO &FRO
  • Encourage a more normal motor patterning.

Adjuncts - We have many choices available to name a few SPIOS, HIP Helpers, Aquatic training, Tapping, Treadmill training

On the Horizon in Care to name a few;

  • Transcranial magnetic stimulation
  • Robot-assisted therapy
  • Virtual reality/biofeedback
  • Electric stimulation
  • Vibration therapy
  • Technology Dream pad
  • Brain computer interface.

Adaptive equipment – we need to look what the child requires, walkers wheelchair adaptive chairs standers & use of different adaptations for use of ADL &Communication.

Home/Community Carryover - Design Strategies for home/school/community that provide carryover of performance achieved in treatment. This may include practice, specific exercises for strength, endurance activities for cardiorespiratory fitness and therapeutic recreational activities that encourage participation.it is very important to spend time empowering the parents & caregivers.

When to abandon/STOP therapy - Transition –from one stage to other

Abandon –therapy no longer produces no functional gain, client declines intervention & client is unable to progress towards functional gains & due to medical/psychosocial issues (APTA standard practice guidelinesM.E.Gannoti.APTA).

Therapy is limited RESOURCE

Let us look at Assessing Effectiveness of therapy –How

many systemic reviews are available, it does not conclude that a particular treatment is the best we have many options available like Context based therapy, CIMT, Goal directed training, bimanual training, Neurodevelopmental treatment and Sensory integration therapy.

Context therapy emphasizes changing the parameters of the task or environment rather than a focus on remediation of a child's abilities. The assumption of this approach is that changes to the task and/or environment will enable the child to perform an activity that they were unable to do previously.

All treatment modalities used in rehabilitation setting were equally effective, the choice for one of these approaches can be adapted to the child's individual situation.

Summary: Clinical Implications

  • Neural Plasticity provides significant hope for the future of persons with Cerebral Palsy. Current and future therapeutic intervention needs to capitalize on this potential.
  • Potential Problems/Roadblocks Neural Plasticity cannot be accessed/maximized if there are fixed mechanical problems e.g., contracture and deformity
  • Musculoskeletal Plasticity may be positively manipulated with early and intensive intervention that influences both neural and muscle plasticity before negative muscle changes develop
  • Continued Research is needed to determine possible treatments for the negative changes in skeletal muscle in patients with Cerebral Palsy.

To conclude--

As rehabilitation professionals, we need to speak with one voice.

  • Early intervention and environmental modifications can prolong safe, independent living for children or adults with disability
  • Health risk monitoring for children or adults with chronic disability is critical across the life course,
  • Prevention of secondary conditions,
  • Education and screening that promote healthy lifestyles
  • Dosing & efficacy of treatment still dilemma.

  Symposium on Stroke (1) Top

  Cognitive rehabilitation in long term stroke care: Return to work Top

Ashima Nehra

Professor and Head, Division of Neuropsychology, Neurosciences, All India Institute of Medical Sciences (AIIMS), New Delhi, India

Together we have to decrease the stroke disease burden in India & bolster their continuum of care.


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