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 Table of Contents  
Year : 2021  |  Volume : 15  |  Issue : 3  |  Page : 85-126

IFNR Oration

Date of Web Publication16-Mar-2022

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How to cite this article:
. IFNR Oration. Physiother - J Indian Assoc Physiother 2021;15, Suppl S1:85-126

How to cite this URL:
. IFNR Oration. Physiother - J Indian Assoc Physiother [serial online] 2021 [cited 2023 Feb 9];15, Suppl S1:85-126. Available from: https://www.pjiap.org/text.asp?2021/15/3/85/339730

  An ounce of prevention is worth a pound of cure Top

  A plea for hip surveillance programs in cerebral palsy Top

Ashok N. Johari

Children's Orthopaedic Centre, Mahim, Mumbai, Maharashtra, India

E-mail: [email protected]

Children with cerebral palsy have a definite incidence of displacement of a hip. Earlier publications showed an incidence of hip displacement of 35% with 15% hips dislocating. Hip displacement is usually silent till it becomes symptomatic. Most patients become symptomatic, lose function, and caregivers have increasing difficulties with progressive hip displacement. Pain is a late symptom increasing in severity and frequency with worsening morphology of the hip, affecting the health-related quality of life.

The incidence of hip displacement has a linear relationship to the GMFCS (Gross Motor Function Classification System) with the non-ambulatory (GMFCS IV & V) having the most marked change in anatomy and higher speed and grades of displacement of 69 – 90%. This hip pathology is also prevalent to a significant degree in marginal ambulators e.g., GMFCS II & III to an extent of 15 – 40%. This demands that the problem be detected much before becoming symptomatic and hence there is a distinct need for early detection and prevention of the progress of hip pathology. With this realization, hip surveillance is a logical next step in the care pathway for our patients.

Large, population-based hip surveillance programmes, started in 1994 with the Swedish Surveillance Program followed by the Australian state programs in 1997. The Swedish data showed a definite reduction of hip dislocation in their study pool with a 0% incidence in their last cohort between 1998 – 2007. The Australian experience has been similar with the need for salvage surgery for hip dislocation eliminated.

Hence the need of the hour for most of Asia and developing countries is surveillance. As an example, India has 2.5 million affected with Cerebral Palsy and hence the prevalence of hip instability could be safely estimated to be over 800,000 cases. Compared to the developed nations, most developing countries have a completely decentralized health care which lacks a system and works mainly in a reactive mode, physician and patient ignorance, socioeconomic problems, long distances and remote corners of the country to cater to! With the many challenges, formulating a national surveillance program with access to therapeutic care seems impossible! With cooperation and collaboration of all stake holders we are striving to create a hip surveillance program for our cerebral palsy patients with the Indian CP Hip Surveillance - Save The Hip Project. This lecture focuses on the creation of the Indian CP Hip Surveillance Program. It is hoped that this program would serve as a model for all developing countries due to the many similarities in health care scenario between them.

  Symposium on traditional therapies in rehabilitation Top

Itgel Bat-Orshikh

Department of Rehabilitation, The Third National Hospital of Mongolia, Ulaanbaatar, Mongolia

What is pranic healing.

  • Pranic healing is a super powerful healing system that uses energy to treat physical & psychological ailments. As of today is being practiced in over a 120 countries worldwide

It is based on 2 principles

  • #1: The principle of Self-Recovery. Which means that the body is capable of healing itself. Imagine you've had a cut, a wound or a burn. Even if you don't treat it, you notice that in a few days the body has healed itself. For this healing to happen, the body needs some kind of fuel. That fuel is energy or Prana. This brings us to the second principle
  • #2: The principle of Life-Force. Which means that for life to exist, the body needs energy or Prana. This also means that if your body has more energy the rate of healing is highly accelerated. Pranic healing can be used to heal all kinds of ailments, ranging from simple to severe or chronic. Pranic healing is also effectively used to treat psychological disorders.

The Grandmaster

  • The Founder: Grand Master Choa Kok Sui Global Pranic Healing. GrandMaster Choa Kok Sui was the founder of Modern Pranic Healing and Arhatic Yoga. He was born in Cebu, Philippines. After years of experimentation and studying esoteric practices such as chi kung, Kabbalah, and yoga, he came up with an energy healing system that is so simple yet so powerful and effective
  • Years later, the science of pranic healing spread from South East Asia to the rest of the world

How does it work

  • There are 2 techniques in pranic healing
  • #1: Cleansing … or removal or dirty deseased energy from the affected area
  • #2: Energizing. That is replenishing the affected area with clean, fresh prana
  • You don't use your own energy. Infact, in Pranic Healing they teach you about different sources of prana or energy.… like the sun, the air and the earth
  • In this day and age, our lives have become so busy that few of us have enough time to sleep and eat regularly, let alone meditate and soul-search. As a consequence of our hectic lives, our physical, mental, and emotional wellbeing are taking a toll. If you believe that physical health, inner peace, and tranquillity have become luxuries only the privileged can afford, we can assure you they're not. The technique of pranic healing can help you restore the life energy your body needs to function properly and live a happier, healthier life.

What is prana

  • The word “prana” originates from the Sanskrit language and means “Life” or “Spirit”.
  • It refers to a universal life force, a hidden form of energy, that exists in all living things, animals, plants, even air, sunlight, earth, sky, rocks, etc
  • Prana is the energy that moves the universe and keeps all of its creatures alive and healthy. All living things absorb prana through sunlight, air, and earth. Their health and wellbeing depend on the amount of prana in them.
  • The three sources of prana
  • The three major sources of prana are Solar Prana, Air Prana, and Ground Prana
  • Solar Prana exists in the sunlight. Sunbathing, sungazing and drinking water charged or exposed to sunlight are all good ways to absorb it
  • 2. Air Prana exists in the air. We absorb it through breathing and through the chakras or energy centres in our etheric body. We can absorb it through the pores on our skin, but the easier way to do it is through deep, slow, rhythmic breathing in nature
  • 3. Ground Prana exists in the ground. It can be absorbed through the minor chakras or pressure points located on the soles of our feet. A simple way to do it is walking barefoot on the ground.

What is pranic healing

  • The two pillars of pranic healing are two essential laws. The first law is the law of self-recovery. The second one is the law of prana or life energy
  • As a science, pranic healing studies our energetic anatomy. Namely, there is an energy field that surrounds every being. Some call it the energy body, the etheric body, the bioplasmic body, or the aura
  • This field can be described as a field of light that penetrates the physical body and extends beyond it to around four to five inches (on average) and acts as some sort of shield. The size depends on the person's health
  • Unfortunately, there are many things in life that can disturb our aura. Things like sadness, loneliness, fear, stress and anxiety all affect our luminous energy field in negative ways
  • As our physical and energy bodies are interconnected, what affects one, affects the other, too. Consequently, we develop long-lasting physical and psychological issues
  • Pranic therapy heals the etheric (energy) body which serves as a protective layer covering the physical body
  • Any malady, dark thought or unhealthy emotion gets in contact with this aura first, before manifesting itself in the physical body
  • It often happens that certain physical symptoms can't show up in a medical report because the illness or disease has come in contact with the person's aura but hasn't yet touched the physical body
  • Maintaining our inner balance and keeping our body/mind in good shape requires implementing healthy habits and taking good care of this energy body
  • This ancient art of healing helps us identify problems and eliminate them while cleansing our aura and restoring its balance
  • The therapy is based on the channelling of pranic energy from the source through the healer towards the one who's being healed
  • Practitioners channelize the life force or prana around us and use it to heal our minds and bodies
  • The healer acts as a channel or medium while the energy acts as a healing tool. Numerous testimonials and researches from around the globe prove that it truly works!
  • The energy body has 11 major chakras. They control and energize our vital organs and affect our mental and spiritual wellbeing
  • Pranic healing helps cleanse, stabilize, and energize all the major chakras and various minor ones when needed
  • Cleansing helps remove the unhealthy energy from the person's body and eliminates blockages in the energy channel so it can soak up fresh energy coming from the healer. Energizing might do more harm than good unless the cleansing is done properly.

What are the benefits of pranic healing

  • The key benefits of pranic healing include:
  • Greater happiness
  • Inner peace
  • Higher degrees of intelligence
  • Fewer health problems
  • Helping others
  • Higher degrees of sensitivity and awareness
  • Improving your intuition.

Morning Meditation

  • Nowadays, being stressed out is a way of life. People constantly feel pressured about money, family, relationships, jobs, schools and who knows what else. What's more, most people accept this stress as an unavoidable part of life. Because of this, and the current fast pace of life, you see people who are unhappy, judgmental, unkind, and most importantly – you see people who do not have peace of mind. Luckily, all of that can change. Peace of mind can be achieved with a simple morning meditation
  • If you meditate in the morning, right before your day starts, you will be able to achieve calmness and change your perspective. By the same token, you will start feeling more positive about yourself, others, and your day to come.

Make Morning Meditation Part of Your Routine

  • Now that you know all the benefits of morning meditation, it is time to try to incorporate it into your morning routine. But we all know how difficult creating new habits can be. Moreover, we all know how difficult committing to those habits is as well
  • However, once you realize that meditation is one of many activities that help overcome stress and anxiety, and simply make people feel better, it will not be that hard incorporating it into your routine
  • Thus, what you can do to help yourself stick to this new routine is a regular practice. Start small. Ten or fifteen minutes a day. Make sure that it is always at the same time and place
  • Choose a room in your home which is quiet. If there is a lot of background noise, you will not be able to concentrate on your meditation, especially if you are a beginner
  • Try to find a quiet and comfortable place in your home and do your morning meditation there, every day, at the same time.

How Long Should You Meditate For

  • The duration of your meditation depends on many things. Of course, it depends on the free time you have available and your preferences. Every person is different, and thus, every meditation will be different
  • Assuming you are a beginner, you should try different time periods and see which one works for you. When starting out, you might feel uncomfortable, so do not force yourself to sit in one position for half an hour just because you heard that a 30-minute meditation works best
  • No, try it for 5 minutes for the first couple of days. Then, after some time, prolong your meditation to 10 minutes. That is the best way to train your mind.

Various Pranic Healing Meditation Techniques:

  • Now, here are a few other Pranic Healing Meditation techniques that have gained extreme popularity among people. However, you can try these out only after you have mastered the basic procedure
  • Arhatic Yoga (safe and fast 'evolution' of the soul)
  • Sexual Alchemy (understanding the spiritual sexuality and learning its techniques)
  • Super Brain Yoga (improved mindfulness, awareness and focus)
  • Meditation on Three Hearts (achieving inner peace and spiritual illumination)
  • Meditation for Soul Realization (knowing about the self, higher soul and inner divinity)
  • Universal and Kabbalistic Meditation on 'The Lord's Prayer' (associating the phrases of 'The Lord's Prayer with the vital energy centers of our body)
  • 'Om Mani Padme Hum' Meditation
  • Kabbalistic Meditation on the 'I AM'
  • Hope the information is helpful
  • Are you interested in meditation. Which type of meditation do you love to practice. Leave us a comment below.

  Aqua Therapy Top

  Aquatic therapy and fitness Top

Beth Scalone

Physical therapist, specializing in orthopedic and aquatic therapy, Owner, North County Water & Sports Therapy Center, CA

The consequence of neurological disease can be physical such as reduced mobility, balance, and endurance. The psychological impact including depression only adds to the physical decline. All leading to a reduced quality of life. Aquatic therapy and exercise has been proven to have multiple benefits addressing these impairments allowing patients to thrive and even recover in some cases. This lecture will review the benefits including latest research on aquatic therapy and aquatic exercise for individuals with neurological disease. Practical tips on programming treatment techniques are included to facilitate understanding and practical application.

  Experience of COVID 19 and Neurorehabilitation Symposium Top

  Neuro rehabilitation in covid patient Top

Bouathep Phoumindr

Orthotist & Prosthetist, Laos

Rehabilitation in case of covid-19 complication with stroke and 2 days later has thrombosis which was caused for above knee amputation.

  Aqua Therapy Top

  Aquatic therapy in neurological rehabilitation “beginning from basics” Top

Brinda Merchant

Training Head, AquaCentric Therapy, Mumbai, Maharashtra, Indai

Aquatic Therapy for Neurological Rehabilitation “Beginning from Basics” Strategies for neurological rehabilitation have evolved over the years. Aquatic rehabilitation is found to be a beneficial therapeutic modality for patients with neurological disorders. The unique properties of water namely those of buoyancy, turbulence, viscosity, hydrostatic pressure and therapeutic warmth enables therapists to design effective and versatile treatment programs. Application of aquatic rehabilitation approaches can influence neurological disorders at all levels of ICF. Movement exploration, strengthening and functional activity training are facilitated and enhanced, often even before patients can perform the same on land. Also, supportive properties of water allow easy handling of patients by aquatic therapy professionals. The therapeutic benefits of aquatic therapy relate to the fundamental principles of hydrodynamics: • Buoyancy • Viscosity • Hydrostatic pressure • Thermodynamics Human body being less dense than water is subjected to buoyancy of water, rather than force of gravity which dominates on land. Gravity loads the body, whereas buoyance off loads the body. Immersion in water up to the chest level, would result in 70% of less loading. Consequently, person feels lighter and therefore experiences decreased joint stress and more mobility than on land. Water allows stability of trunk without relying on use of upper limbs as is often the case during land-based exercises. Postural stability in standing is enhanced as water acts as a supportive medium. This when combined with movement strategies promotes better alignment and postural control while standing. Viscosity or drag force refers to resistive force provided by water to movement, providing natural resistance and increased sensory stimulation. Muscle strengthening is hence facilitated as the body needs to work against viscosity. Force can be altered with use of pool equipment like resistance jets, diving fins, kickboards and pool noodles. Hydrostatic pressure is pressure exerted by water on body during submersion. Hydrostatic pressure assists in resolution of edema, increase in joint range of motion and tone modulation. Warm water in aquatic therapy pool promotes pain relief, muscle relaxation, enhances circulation and general comfort. Ideal temperature for therapeutic pools is 32.5 degrees Celsius, which is thermo-neutral for the human body. However, in conditions like pregnancy and multiple sclerosis, a cooler pool temperature of 25-28 degrees Celsius is required. Motor Control Models in Aquatic Therapy[1],[2] The task-oriented approach incorporates principles from muscle reeducation model and neuro therapeutic facilitation model[1] Systems approach of motor approach is an interaction of task, person and environment. Aquatic therapy interventions comprise of techniques which utilize physical properties of water. These include Water Specific Therapy (WST), Bad Ragaz Ring Method (BRRM), Aquatic Strengthening, Functional training and Clinical Ai-Chi. An important factor for deriving functional benefits is having skilled aquatic therapists design a treatment program customized as per individual's functional ability and limitations. Depending on individual needs, frequency of session may be 3-5 times a week with session duration of 45 minutes. Ten-point Halliwick program/Water Specific Therapy [2],[3] The HaIliwick Method, best described as a neuro therapeutic facilitation rehabilitation technique, follows a disengagement principle. Therapists/instructors use activities to facilitate patterns of movement with careful consideration of the activity's level of difficulty and the amount of manual guidance provided. Specifically, therapists/instructors start with easy activities and manually guide the patient to assure correct execution of the movement. As the patient becomes more skilled with the movement, the therapist/instructor reduces the amount of assistance provided (disengaging) and increases the activity's level of difficulty. Phase 1: Adjustment to Water Mental adjustment Disengagement Phase 2: Rotation Control Vertical rotation control Lateral rotation control Combined rotation control Phase 3: Control of Movement in Water Use of up thrust Balance-in stillness Turbulent gliding Phase 4: Movement in Water Basic progression Swimming progression Bad Ragaz Ring Method[4] Bad Ragaz method is a model of resistive exercises to strengthen and mobilize possessing a variety of features • presents a specific therapeutic regimen, with well-defined indications; • is an ideal part of comprehensive treatment concept in aquatic therapy; • analyzing functional therapeutic targets and functional limitations of the patient and then choose the most suitable models; • represents a base for improving strength, mobility, stability or body functions; Task Type Training Approach in aquatic therapy[2] The TTTA can be best described as a task-oriented approach. Patients are encouraged to become active problem solvers of their movement difficulties as opposed to passive recipients of manual and/or verbal input from therapists. 1. Work in the shallowest water tolerated. 2. Practice functional activities as a whole. 3. Systematically remove external stabilization provided for patients. 4. Encourage stabilizing contractions in upright positions with movement of selected body segments. 5. Encourage quick, reciprocal movement. 6. Encourage active movement problem solving. Aquatic therapy pools are designed to meet functional goals and for enhancing recovery from paralysis. Improved standing and gait is a primary therapeutic goal. Hence pools are adapted to facilitate therapeutic activities while standing. It is ideal to have incremental pool depth ranging from shallow to deep for treatment interventions. Side rails are an essential feature to provide requisite support. Pool staircase has an anti-skid surface with side rails for safe entry and exit. Special features include: • Underwater Treadmill: Invaluable for gait training, underwater treadmill allows individuals to practice walking patterns which mimic land patterns. The speed of the underwater treadmill changes in small increments allowing persons to safely progress at their own speed. • Underwater Cameras: These enable real time monitoring of gait and movement patterns without looking down, so that corrective feedback may be provided by the physiotherapist immediately • Electronic pool hoist: Persons with spinal cord injuries may frequently have mobility issues that which make entry and exit difficult. Electronic pool hoists are used to facilitate entry and exit, making pool safe accessible for persons of all ages and abilities, eliminating need for ladders or steps. • Resistance Jets: Variable speed resistance jets allow physiotherapist to adjust the level of water pressure and vary resistance offered by water, thereby altering exercise intensity. • Deep-tissue Massage: In pool, high pressure massage hose allows deep tissue release, reducing the amount of muscle soreness and promoting a faster recovery. • Height adjustable drop in platforms: These are sturdy, on slip surfaces above level of pool floor. Sitting based exercises and other strategies of water specific therapy (WST) are facilitated using pool platforms • Underwater stationary cycle and elliptical trainers: These are designed for improvement of cardiovascular endurance. Aquatic therapy equipment comprises of water dumbbells, foam rollers, resistance band, boards, floatation vests, neck collars, pelvis rings and snorkels. Pool surroundings are required to be accessible in terms of design. Pool deck, changing room and wash room facilities are wheelchair accessible, with wide doorways and adequate room for wheel chair maneuvering. Anti-skid flooring is installed in all areas. Wide benches need to be provided. Hand rails are installed at strategic locations Trained support staff assist with safe transfers. Nursing personnel assist with assessment of vital parameters, bladder management and wound dressing. Precautions are taken in case of co-existing lung or heart conditions, ear infections, open wounds, inserted lined/tubes and unregulated bowel/bladder incontinence. Aquatic exercise should not be attempted in case of uncontrolled seizures or conditions classified as medically fragile. It is important to seek medical clearance prior to start of therapy.


  1. Morris DM. Aquatic rehabilitation for the treatment of neurological disorders. J Back Musculoskelet Rehabil 1994;4:297-308.
  2. Horak FB. Assumptions underlying motor control for neurologic rehabilitation. In: Lister MJ, editor. Contemporary Management of Motor Control Problems Proceedings of the II STEP Conference. Alexandria, VA: Foundation for Physical Therapy; 1990. p. 11.
  3. Boyle AM. The Bad Ragaz ring method. Physiotherapy 1981;67:265-8.
  4. Martin J. The Halliwick method. Physiotherapy 1981;67:288-91.

  View Point from Vietnam Top

Cao Minh Chau1,2

1Faculty of Medical Technology, Phenikaa University, Hanoi, 2Vietnam Rehabilitation Association, Vietnam

1. Vietnam Country

Vietnam borders China to the North; Laos & Cambodia to the Westen; Easten Sea to the East.


2019: 96.208.984 people.

  • Vietnam becomes the 15th most populous country in the world and the 3rd in Southeast Asia
  • Currently 75% of the population is under 35 years old, the average life expectancy is 73, but the population is aging rapidly


  • Vietnam has an area of 332,212 km2 of land, more than 4,200 km2 of Islands and sea
  • Vietnam has 63 provinces and cities.
  • Each province or city is divided into districts and districts divided into communes


Diversity: 45,3% Folk beliefs, 27.9% non-religious, 12,2% Buddhist, 6,8% Catolic, 4,8% Cao dai, 3% other


After 25 years of reform, Vietnam has gone from being one of the poorest countries in the world to becoming a middle-income county.


  • Vietnamese
  • Literacy rate is 98%

Rehabilitation needs

2019. Survey results: more than 7% of the population aged over 2 years equivalent to about 6.2 million people with disabilities and 13% (equivalent 12 million) people live in a household with PWDs



- Period before April 27, 2021 Vietnam has well controlled covid 19.

- From April 27 to now, Vietnam has > 200,000 cases (by MOH) of covid 19, of which 55558 have been cured.

- Most infections are in Ho Chi Minh City and some southern provinces of Vietnam

- Today the number of infections of covid 19 is reduced step by step

- The Government intervened very drastically and promptly at the outbreak site

- Social distancing plays an important role in limiting Community transmission

- The Government issued a policy where the epidemic broke out: family distanced from family, community distanced from community, district distanced from district, province distanced from province.

- People at home are “patriotic”

- The Government set up a lot of checkpoints to check people entering the market, entering the community, going in and out of the district, going in and out of the province, in and out of the country's borders.

- People infected with F0 are treated at the hospital, F1, F2 can be isolated at home with the control of authorities and medical staff.

- People infected with F1, F2 who test positive for covid 19 are isolated at makeshift hospitals

- Local Government only allow people to go out to buy essential items such as food, water, medicine, go to the hospital for emergency.

- Each family only gives out a limited number of vouchers to go to the market on a certain day

- Everyone implements 5K of the Ministry of Health

- 5“K” (K hẩu trang, k hử khuẩn tay, k hoửng cách, k hông tập trung, k hai báo y tế) are: Wear a mask, disinfect your hands, stand a long distance away, do not gather in crowds and make a medical declaration

- Preventive medicine plays an important role in preventing and tracing people infected with covid 19

- Vaccination + serious social distancing + information technology application are the keys to success in the fight against covid 19 infection, especially Delta variant

- “Fighting against covid 19 is like fighting the enemy”


3. 1. The common problems

3. 2. Principle of intrvention

  • Early detection & early intervention
  • Multidisciplinary Rehabilitation Team

3. 3. Stages of Rehabilitation

  • Hospitalization stage: Physiotherapy, kinesiotherapy, OT, ST,
  • Modern Technology: TMS, Robotic for Upper limb, Robotic for Lower limb.
  • Transition stage: Patients stay in transfer houses for some weeks for training living in their house. Patients learn more ADLs, Adaptive devices
  • Community Based Rehabilitation: Patients, family members, CBR Workers are working toghether.
  • Severely People with disabilities (PWDs) are admitted to the hospital for treatment, rehabilitation as well as compliance with measures to prevent the spread of Covid-19 in the hospital.
  • Stable People with disabilities receive treatment and rehabilitation at home. They are consulted by phone, zalo, Website, Telemedicine in places where information technology can be deployed.


  • Neurological disorders are common problems in Vietnam during Covid 19 period such as: Stroke, Spinal Cord Injury, MS, Dimentia, Parkinson, Neurological Pain, Headache, CP.
  • Need for multidisciplinary coordination in Rehabilitation
  • Patients with neurological diseases need to be rehabilitation in the hospital, acclimatized at the transit home, and then returned to rehabilitation at home or in the community

  Experience of COVID 19 and Neurorehabilitation Symposium Top

  Mental Health and fear of contagion among health care professionals during COVID-19 pandemia: Results of an Italian survey Top

Caterina Pistarini

Assistant Professor of Neurorehabilitation, University of L'Aquila

Our study underlines the negative effects of the COVID-19 pandemia on psychological wellbeing of Italian health care professionals.This can lead to an increased risk of burnout. This study suggests that intervention policies should include strategies to promote resilience (see, for example, Klockner et al., 2021; Heath et al., 2020) and the development of stress management practices (Neto et al., 2020). Tailored interventions need to be implemented for reducing psychological burden with a particular attention to nurses.

[TAG:2]Challenges in visual neglect [/TAG:2]

  rehabilitation Top

Charumati Raghavan

Psychologist, Pune, India

(Summary of presentation for AOCNR 2021)

Visual neglect is a disabling disorder which commonly occurs post stroke. Patients with visual neglect fail to pay attention to stimuli on the side of space contralateral to the side of brain damage. Neglect is a known predictor of poor functional recovery (Jehkonen et al., 2006) and may affect rehabilitation of motor deficits post stroke. However, lack of sensitive and timely screening of cognitive deficits, presence of co-existing deficits like poor comprehension, sustained attention and anosognosia and transient effects of rehabilitation may complicate recovery.

Research has shown that Transcranial magnetic stimulation (TMS) has promising benefits in facilitating recovery from neglect lasting up to 4-6 weeks post sessions (for review, Lefaucheuer et al., 2020). The framework for TMS use in neglect rehabilitation is based on the Interhemispheric Rivalry theory (Kinsbourne, 1977). TMS involves non-invasive electromagnetic stimulation of neuronal activity in the brain's attentional networks over multiple sessions intended to re-balance interhemispheric functional activity disrupted due to brain damage.

Long term efficacy of theta burst paradigms and combining TMS with other cognitive rehabilitation methods are currently being explored. Future research would benefit from evaluating effects of varied stimulation protocols and inter-individual differences in guiding TMS-based rehabilitation efforts.


  1. Jehkonen M, Laihosalo M, Kettunen JE. Impact of neglect on functional outcome after stroke: A review of methodological issues and recent research findings. Restor Neurol Neurosci 2006;24:209-15.
  2. Lefaucheur J, André-obadia N, Antal A, Ayache SS, Baeken C, Benninger DH, et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clin Neurophysiol 2014;125:2150-206.
  3. Kinsbourne M. Hemi-neglect and hemisphere rivalry. In: Weinstein EA, Friedland RP, editors. Hemi-Inattention and Hemisphere Specialization (Advances in neurology, p. 41-49). New York: Raven; 1977.

  Unravel cognitive processing speed in rehabilitation Top

Chetwyn Chan

Chair Professor, Department of Psychology, The Education University of Hong Kong, Tai Po, China

Processing speed is an important outcome measure in rehabilitation. Reaction time is a common measure of the outcome. In this presentation, the results of two brain imaging studies will be presented to shed light on the possible neural mechanisms underlying processing speed. By using a 2-by-3 task design, we managed to isolate the cognitive component of the processing speed. Functional brain imaging results revealed frontocerebellar connectivity predicting the participants' reaction times specific to the cognitive processes (Wong et al., 2021). The long-range connections relate to cognitive control, while the short-range connections relate to rule-based stimulus-response processes. Using a different approach, the results based on resting-state signals revealed within-network connectivities in the motor and visual networks subserving the faster processing speed. In contrast, we found the between-network connectivities in the motor- subcortical and cerebellum, and the motor-frontoparietal networks to subserve the slower-processing speed. The findings of these two studies inform processing speed involves complex neural processes. The future design of interventions for improving processing speed can adopt a neural network approach and refine the task design with specific treatment goals.

  Paediatric Rehabilitation Top

  Strategies for successful participation: Lessons from adults with cerebral palsy Top

Christine Imms

Department of Paediatrics, The University of Melbourne, Melbourne, Australia E-mail: [email protected]

Introduction: The United Nations Convention on the rights of people with disability calls for their equitable participation and inclusion in society.[1] Many countries, including Australia, are signatories to the Convention. Despite the intent to create a society in which all people experience equity of opportunity to participate, adults with cerebral palsy, along with other people with disability arising in association with other conditions, continue to experience significant barriers and restrictions to their participation.[2],[3] In the past decade, Australia has undertaken significant policy reform, associated with a 10-year National Disability Strategy that aimed to address disparities through increased visibility of the issues, engagement with the disability community, and changes in disability investment and resource allocation.[4] In 2013, new legislation introduced Australia's National Disability Insurance Scheme (NIDS)[5] to give individuals with disability choice and control over the necessary and reasonable services and supports they required. Thus, organisations were no longer funded to provide services, individuals were funded to purchase services.[6] People with cerebral palsy only form about 5% of the participants of the NDIS, however their annual support packages are the second highest in dollar value.[7] This finding adds an economic imperative to the social imperative to understand the supports required to build capacity and optimise participation outcomes in this group. Approach We conducted two independent studies that addressed participation outcomes of adults with cerebral palsy living in Victoria, Australia. One study explored the social outcomes of school leavers (aged 18 to 25 years) using survey methods and comparisons with population-based data from non-disabled peers.[8] The second study, undertaken with adults with cerebral palsy (aged 23 to 47 years) used qualitative methods to explore how they had successfully negotiated the challenges of adulthood.[9] Both studies examined participation in education, employment, independent living, friendships and intimate relationships, and other community activities. The overall purpose of the studies was to understand where participation disparities continued to exist and identify strategies that had enabled adults with cerebral palsy to achieve participation success. Our goal was to inform adults and young people with cerebral palsy, their families and allies, about aspects that may enable their own participation. In addition, we sought to provide knowledge to practitioners and service providers about helpful approaches and important barriers. Social outcomes in young adults with cerebral palsy In the survey-methods study we used the Victorian Cerebral Palsy Register (VCPR) to recruit 90 young adults aged between 18-25 years (mean age 22.4 years (SD: 2.2) in 2020) of whom 57% were male and 61.1% provided a self-report (remainder by proxy). Respondents were broadly representative of the cerebral palsy population (gender, age, topography, mobility, speech, intellectual and sensory impairments) as determined through a comparison between respondents and non-respondents using de-identified VCPR data. The sample included individuals classified in each level of the Gross Motor Function Classification System (GMFCS)[10] with 29.1% at Level I, 30.2% at Level II, 12.8% at Level III, 15.1% at Level IV and 12.8% at Level V. In addition, respondents included individuals at each level of the Manual Ability Classification System,[11] Communication Function Classification System,[12] and the Eating and Drinking Ability Classification System,[13] as determined by self- or proxy-report. We collected data on social outcomes and made comparisons with (1) non-disabled peers using an age-equivalent cohort from the population-based Household Income and Labour Dynamics in Australia survey;[14] and (2) with data collected in 2007 by our group on young adults with cerebral palsy (aged 20-30, mean age 24.7 years, SD 2.8). In addition, we explored determinants of outcomes in further education, employment and independent living, and measured life satisfaction. Findings demonstrated positive changes in proportions completing foundational education since 2007 (now 80% compared to 50%), however, we also found little change over time in further education outcomes or employment status and significant disparity with their same aged peers. Having higher functional capacity was associated with both further education and employment, however, not all those with higher functional capacity were participating. Contextual factors – many of which are known and modifiable – were reported by young adults to continue to create barriers to participation. In comparison to their same aged non-disabled peers, very few were living away from the parental home (12.5% compared to 51.8%), and only 3.4% reported being married or partnered compared with 31.6% of their peers. Because so few participants were partnered it was not possible to explore determinants, however only a half to two-thirds reported having complete choice over who they spent time with, how they spent their time or their money. In addition, their life satisfaction was lower than similar aged peers. Experiences associated with successfully negotiating adult life Our qualitative study,[9] informed by interpretative description methods,[15] recruited adults who were interested to explore with us what enabled them to successfully participate in different aspects of adult life. Included were 23 adults (aged 23-47 years; 10 male, 13 female) across GMFCS[10] levels I to IV (n = 5 Level I, n = 7 Level II, n = 7 Level III and n = 4 Level IV) and CFCS[12] levels I to III (n = 16 Level I, n = 4 Level II and n = 3 Level III). We used individual semi-structured interviews to explore participation in major areas of adult life (e.g., education, employment, relationships, living situation, health care). We asked how they had successfully negotiated these aspects of life, what contributed to their success, and what supports were, or would have been, helpful. As all participants had faced challenges they had not been able to address we were also able to explore what strategies had been tried in these situations.[9] Participants discussed many aspects of life, and across the sample, five were studying, ten were employed, 11 were living independently, six were in intimate relationships and two were parents. Inductive analysis of the interview data resulted in one theme that was common to all life situations – doing what others do – and an organizing framework that comprised four thematic areas and their subthemes. The four thematic areas were: formative experiences that set them up for success in adulthood; present contexts in relation to supports, accommodations and expectations; present functioning underpinned by a positive self-concept, well-honed social skills, physical fitness and ability to find a way; and finding a way which involved drawing on their knowledge and skills, gravitating to those who understand difference, maintaining their function and using their supports.[9] Using what is learned Evidence from these studies confirms the continued need to build supportive environments for children, youth and adults with cerebral palsy. While poorer social outcomes for some individuals can be explained by significant or profound impairment, that is not true for many. Current evidence points to participation-focused approaches as being the most effective way to address participation outcomes: [16] that is, using participation as both a means and an ends.[17] The evidence from these two studies will be used to highlight opportunities through childhood and into adulthood to support successful participation of young people with cerebral palsy. While the findings are Australian – and therefore influenced by cultural, social and political contexts – many of the issues identified, and strategies suggested, are universally applicable or could be tailored to new contexts. Indeed, tailoring is one of the key elements of effective participation approaches.[16] People with lived experience of cerebral palsy have deep knowledge of what works for them. Authentic partnering in research and translation, practice and policy development and implementation, is likely to increase the pace of change towards inclusion in our societies. Conclusion: Despite significant policy reform over the past decade, Australian young adults with cerebral palsy continue to experience significant participation restrictions in important aspects of life: further education, employment, living situation, friendships and intimate relationships. Evidence from these studies points to key aspects of the early-life experiences of those with cerebral palsy that need to be targeted. We need to create environments in which young people can receive incremental support for skill development, build positive self-concepts and confidence, and have and use appropriate supports, so that they too can live a good life.


  1. UN General Assembly. Convention on the Rights of Persons with Disabilities 2007. Available from: https://www.refworld.org/docid/45f973632.html.
  2. Lindsay S. Child and youth experiences and perspectives of cerebral palsy: A qualitative systematic review. Child Care Health Dev 2016;42:153-75.
  3. Reddihough DS, Jiang B, Lanigan A, Reid SM, Walstab JE, Davis E. Social outcomes of young adults with cerebral palsy. J Intellect Dev Disabil 2013;38:215-22.
  4. Council of Australian Governments. 2010-2020 National Disability Strategy2011. Available from: https://www.dss.gov.au/sites/default/files/documents/05_2012/national_disability_strategy_2010_2020.pdf.
  5. Reddihough DS, Meehan E, Stott NS, Delacy MJ; Australian Cerebral Palsy Register Group. The national disability insurance scheme: A time for real change in Australia. Dev Med Child Neurol 2016;58 Suppl 2:66-70.
  6. Carey G, Malbon E, Olney S, et al. The personalisation agenda: The case of the Australian national disability insurance scheme. Int Rev Sociol 2018;28:20-34.
  7. Deloitte Access Economics. The Cost of Cerebral Palsy in Australia in 2018. Sydney, Australia: Report Prepared for Cerebral Palsy Australia, Cerebral Palsy Alliance and The Australasian Academy of Cerebral Palsy and Developmental Medicine; 2020. p. 1-67.
  8. Imms C, Reddihough D, Shepherd DA, et al. Social outcomes of school leavers with cerebral palsy livingin Victoria. Front Neurol Pediatr Neurol 2021.
  9. Gaskin CJ, Imms C, R Dagley G, Msall ME, Reddihough D. Successfully negotiating life challenges: Learnings from adults with cerebral palsy. Qual Health Res 2021;31:2176-93.
  10. Palisano RJ, Rosenbaum P, Bartlett D, Livingston MH. Content validity of the expanded and revised gross motor function classification system. Dev Med Child Neurol 2008;50:744-50.
  11. Eliasson AC, Krumlinde-Sundholm L, Rösblad B, Beckung E, Arner M, Ohrvall AM, et al. The manual ability classification system (MACS) for children with cerebral palsy: Scale development and evidence of validity and reliability. Dev Med Child Neurol 2006;48:549-54.
  12. Hidecker MJ, Paneth N, Rosenbaum PL, Kent RD, Lillie J, Eulenberg JB, et al. Developing and validating the communication function classification system for individuals with cerebral palsy. Dev Med Child Neurol 2011;53:704-10.
  13. Tschirren L, Bauer S, Hanser C, Marsico P, Sellers D, van Hedel HJ. The eating and drinking ability classification system: Concurrent validity and reliability in children with cerebral palsy. Dev Med Child Neurol 2018;60:611-7.
  14. Department of Social Services. The household, income and labour dynamics in Australia (HILDA) survey, GENERAL RELEASE 19 (Wave 1-19). In: Research MIoAEaS, editor. ADA Dataverse. 5th ed. The Unviersity of Melbourne: 2020.
  15. Thorne S. Interpretive Description: Qualitative Research for Applied Practice. New York, NY: Taylor and Francis; 2016.
  16. Anaby D, Khetani M, Piskur B, van der Holst M, Bedell G, Schakel F, et al. Towards a paradigm shift in pediatric rehabilitation: Accelerating the uptake of evidence on participation into routine clinical practice. Disabil Rehabil 2021;1-12.
  17. Imms C, Granlund M, Wilson PH, Steenbergen B, Rosenbaum PL, Gordon AM. Participation, both a means and an end: A conceptual analysis of processes and outcomes in childhood disability. Dev Med Child Neurol 2017;59:16-25.

  Symposium on Disorder of Counsiousness Top

  Disorders of consciousness in India: Preliminary results from a pilot survey Top

Davide Sattin

Physiatrist, Milan, Italy

Despite the increased number of articles published on Disorders of consciousness (DOC), the epidemiological data of this population is largely unknown. In addition, to develop universally accepted diagnostic criteria and to plan adequate welfare interventions, ad hoc systems for the collection of epidemiological data are necessary for establishing valid epidemiological information. Therefore, it is a challenge to establish the incidence of DOC, and some incidence data have been provided although there is no uniform system of care and marked cultural, economic, and health policy differences in the approach to care for patients with DOC. Prevalence estimates are as scarce as incidence rates, but available data indicate that patients who survive the first year in a Vegetative State have a high probability of living for many years, albeit with severe disability. The epidemiological data of Indian patients with DOC, specifically vegetative state and minimally conscious state, have not been investigated at the moment. In the present lecture, we aim to explore the current state of the art in India for patients with DOC reporting results from a pilot survey realized in 2017. We analyzed data collected involving 52 Indian professionals who declared that their centers hospitalized patients with DOC in the last year for rehabilitation/medical treatments. The majority of the professionals were from the Maharashtra region. The main preliminary findings showed that the prevalence rates of traumatic and non-traumatic etiologies were equally distributed, that the rate of use of the coma recovery scale revised was low and that the re-hospitalization was always or frequently possible in neurological and rehabilitation units. The extrapolated estimated rate of patients with DOC hospitalized in the centers involved in 2017 was equal to 4 per million of the population in the Maharashtra region. More than 50% of the professionals declared that there were neither sufficient nor adequate services for caregivers' support. Even if the present pilot survey has some limitations, the present article offers the first preliminary data on patients with DOC in the Indian country. Research realized by: Fondazione IRCCS Istituto Neurologico C.Besta, Milan, Italy. WFNR-RVP South asia-Mumbai, Maharashtra, India Istituti Clinici Scientifici S.Maugeri, Pavia, Italy Istituto S.Anna, Crotone, Italy.

  Symposium on Motor Neurone Disease Top

  Occupational therapy in MND Top

Deepa Sundareswaran

College of Occupational Therapy, National Institute of Physical Medicine and Rehabilitation, Thrissur, Kerala, India

'When everyone says you can't, determination says.yes you can;! Robert Hensel.


Occupational therapists supporting people with MND should aim to: Liaise with occupational therapists in different settings, particularly to avoid repeat assessments. Liaise with professionals from other disciplines to ensure integration of systems, Coordinate visits with other professionals where possible. Signpost the person, their family and carers to other relevant services.“

Principles of Occupational Therapy

The occupational therapist should consider assessing and advising on, among other things: Optimisation of meaningful activities of daily living, and what is important to the person Maintenance of social and leisure activities for as long as possible Modification of the home environment to take account of declining function and mobility and occupational performance Raising awareness of safety Posture and positioning Fatigue management and conservation of energy Psychological strategies Avoiding undesired hospital admission Use of adaptive equipment, include potential future needs Facilitation of meaning, quality of life and well-being Providing support around physical, emotional and spiritual issues Promoting a positive approach to death. Equipment may include aids to support personal care, posture and mobility. This may include specialist head and neck supports, static seating and wheelchairs, mobile arm supports, switches and other devices for accessing computers and using environmental control system. 'Occupational therapy takes a whole-person approach to both mental and physical health and wellbeing, enabling individuals to achieve their full potential' Occupational therapists can: 1. Maximise functional abilities as far as possible to minimise the 2. impact of MND on activities of daily living 3. Help the person adjust to changing roles 4. Facilitate the realisation of meaningful goals 5. Offer person-centred assessment and intervention 6. Explore and trial strategies to enable choice and control 7. Facilitate exploration of future needs. 8. Support people with MND and their families. 9 Support people with MND to achieve good quality of life in a holistic way. 10. Support family and carers, throughout the course of the condition and in bereavement. By exploring and offering possible solutions, the person with MND is offered: Support to adapt to changing symptoms Maintenance of occupational participation and quality of life Choice and control.

The Occupational Therapy Process

The assessment process: Assessment needs to be holistic and timely covering physical, psychological, emotional, social, spiritual and financial needs are essential for creating and reviewing comprehensive care plans for a person with MND. When selecting an assessment tool, consider: Information already gathered from previous assessments Reason for referral Expectations of the person and their family The purpose of the assessment. Occupational therapists should proactively anticipate what equipment and adaptations may help to enable the person with MND to participate in occupations. “The ability to adapt to change can make such a Difference to the experience of living with MND.” (A person living with MND) Without appropriate and timely intervention, someone experiencing deterioration may end their independence and activities restricted, leading to feelings of despair and frustration. Creative solutions may be required when considering particular types of equipment. For example: POSSIBLE BARRIER POSSIBLE SOLUTION Adaptations that change the look of the home, associating it with disability Consider blending a ramp into the existing property rather than using an obvious metal structure. Encourage the person to consider their enhanced independence as a result of adaptations Resistance to living on a single level of the home Interim hired stairlift while the person is able to safely use one and continue to plan for the future. Discuss positives such as being able to go outside, if downstairs As MND progresses It is essential that people are advised on positioning and assisting movement. Consider: The carer supporting the arms when moving The person having their arms supported, either by armrests or with pillows/cushions while seated Referral to orthotics for shoulder or arm support. Seated posture As MND progresses, the person will spend more time sitting and will be less able to adjust their own position or stay upright against the effects of gravity. Inadequate support can lead to poor posture, affecting function and distribution of weight, which may lead to pressure sores. The preferred position for someone with MND and neck weakness is tilted back, with their arms, back, head and neck supported. The aim is to support posture to maximise function, while minimising risk of deformity and pressure injury. This may be achieved with seating with greater postural support, including a backrest shaped to the spine. Options may include: A posturally supportive armchair A riser/recliner chair with a waterfall type back to support the neck and lumbar region of the spine More supportive seating may be indicated following assessment. Separate back rest and seat adjustments for posture and comfort Wide arm rests with pressure relieving qualities Wheelchair head supports. Consider: People with MND retain sensation, so will know when they need to move, or need help to be moved Those with communication difficulties may not be able to express that they want to be repositioned Appropriate cushioning for seating and wheelchairs to provide pressure relief Seating (including shower and bathroom chairs) that accommodates and supports postural limitations Use of barrier creams. Head and neck support Head drop can lead to difficulties with correct positioning for speaking, breathing and eating A tilt-in-space feature on a wheelchair or riser recliner armchair can help keep the trunk and head in a more upright position. Seating backrests should accommodate the shape of the spine to enable the head to be supported. Depending on level of need, options may include: Rails and bars to aid bed mobility Low friction slide sheets (advise on nightwear to avoid excessive slide) A static or powered pillow lift Raising a bed to allow clearance for a mobile hoist under the bed. This will also help with sitting to standing transfers Hoisting By the time hoisting needs to be considered, the person with MND will have already experienced much functional loss. Accepting the prospect of hoisting can be difficult for some people. It is essential to provide the person with reassurance and time to consider the need for a hoist, in order to facilitate acceptance The occupational therapist can advise on: Posture and positioning, including solutions to counter Fatigue management Using fans and increasing air flow to reduce psychological feelings of breathlessness Techniques and strategies to manage anxiety or breathlessness Cognitive changes Up to half of people with MND will experience some degree of cognitive change. Changes may be subtle or more noticeable and may cause problems with some some degree of cognitive change. Changes may be subtle or more may cause problems with Learning new tasks, including the use of equipment (such as powered wheelchairs or environmental controls) Lack of awareness or insight into their problems or their impact Poor concentration Inappropriate social behaviour Impulsivity, which can include repetitive or persistent actions Literacy and language Making decisions, reasoning and problem solving Planning for the future Inflexibility in thought or how activities are undertaken. COMMUNICATION An occupational therapist may support communication with: Eating, positioning, wrist, hand, finger, head and neck supports Switches and pointers Mobile arm supports Tables to access communication aids Equipment to support computer use for communications Environmental controls. The assessment and management of factors related to swallowing, eating and drinking that come under the responsibility of the occupational therapist (NICE GUIDELINE) These include factors related to swallowing, eating and drinking that come under Positioning, seating and posture Strategies for eating and drinking in social situations Use of eating and drinking aids and adapted utensils Advice and help with food preparation. Posture Consider: 1. The position for eating – what type of chair, where table is in relation to the chair, and the distance between plate and mouth (how far they have to lift food to reach mouth) 2. An upright posture and tucking the chin down to the chest when swallowing can prevent food aspiration 3. Head and neck supports Equipment Consider, where it is appropriate to the individual SELF CARE: Equipment and adaptations can maximise the independence of a person with MND, but as the disease progresses, they are likely to need support to manage their personal care. The needs and preferences of the person with MND should be discussed, with information and support provided as needed. Wherever possible, personal care should be carried out by familiar care workers, known to the person and their family and carer.


An occupational therapist with the following three visions helps to improve the quality of life in persons with MND.

Symposium on Dance, Art and Music Therapy

  Dance therapy and neurorehabilitation Top

Devika Mehta Kadam

Program Head, St. Xaviers College, Mumbai, India

Dance movement therapy (DMT) is a creative process that therapeutically intervenes to integrate physical, social, emotional and cognitive functioning. In any neurological illness, one or more of these domains is impaired and DMT offers a pathway that is based in neuroscience and mental health. This presentation aims to highlight the scope of practice, the therapeutic elements of DMT, provide neuroscientific factors impacting the work in DMT, a culturally inclusive perspective and the shift from hospital and rehabilitation centre to an online platform. It hopes to highlight the benefits and advantages of DMT being offered in various medical and mental health setups.

  Symposium by Neurological Society of India Top

  Neurorehabilitation after traumatic brain injury Top

Dhaval Shukla

Professor of Neurosurgery National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India

About 10-15% of patients following mild TBI, 40-50% after moderate, and almost 100% after severe TBI have one or the other disability, requiring rehabilitation. Evaluation • A person with TBI should be evaluated and treated for impairments in cognition, vision, speech and language, behavior, swallowing, sensory-motor system, and bowel and bladder function. • Any patient with TBI who has persistent and stable neurological deficit, who requires medical monitoring and has impairment in two or more key domains should be transferred to an in-patient neurorehabilitation facility. Recommendations for neurorehabilitation facilities • There should be provision for inpatient rehabilitation beds, manpower, equipment, and space to provide optimum care in proportion to acute care. • Each Level I center managing traumatic brain injury must have integrated multidisciplinary in-patient rehabilitation services. • It is recommended for Level II center managing TBI to have integrated multidisciplinary inpatient rehabilitation services. • If in house rehabilitation facilities are not available then a referral to a rehabilitation physician (physiatrist) should be done, and treatment plan should be obtained for rehabilitation in nursing home or at home. Rehabilitation team a. Rehabilitation Physician (Physiatrist). b. Neuropsychologist. c. Speech & language pathologist. d. Physical therapist. e. Occupational therapist. f. Rehabilitation nurse. g. Orthotist. h. Social worker. i. Access to other medical specialties as best available in the setting. Recommendations for nursing homes where rehabilitation facilities are not available In-patient management Disorders of consciousness Skin care to treat or help prevent pressure sores Care to prevent choking and facilitate breathing Management of Urine and Feces Reducing the Risk of Limb Deformity Spasticity Eating and Drinking Sleep and Rest Washing and Bathing Walking Agitation and Destructive Behavior Out patient management The following issues can be addressed at outpatient level: • Speech and language • Headache • Vertigo • Cognitive rehabilitation • Psychiatric symptoms • Continuation of rehabilitation for motor impairments in ambulatory patient Indications for referral to a specialist Neurosurgeon: • Craniotomy site persistent pus discharge (may be bone flap osteomyelitis). • Cranioplasty for patients who have undergone decompressive craniectomy. • Usually 3-6 months after injury. • May consider early if patient has recovered and ready to go for work, scalp is sunken, and local headache. • Post-traumatic Hydrocephalus • Suspect when recovery halts or when patient starts deteriorating after initial recovery. • Chronic Subdural Hematoma (CSDH). • Suspect when new onset headache days after injury. • New onset neurological deficits days after injury. • Suspect when patient starts deteriorating after initial recovery. Neurologist: • Seizure while on antiepileptic drug (consider cognitive side effects of AEDs before adding new drug). • Post-traumatic headache not responding to NSAIDs or amitriptyline Rehabilitation specialist: • Spasticity. • For pressure sores not responding to dressings and position change. Orthopedic surgeon: • Heterotopic ossification o Suspect when painful restriction of joints with swelling Chest physician: • Pneumonia • Venous thromboembolism Urologist: • Recurrent urinary tract infection • Complication of neurogenic bladder (urinary stone, pyelonephritis). Gastroenterologist: • For percutaneous endoscopic gastrostomy (PEG) if patient cannot be fed orally for many days or in UWS/MCS. Psychiatrist: • Depression • Psychosis • Substance abuse prior to or after injury Outcome Assessment • Glasgow Coma Scale during acute care, and at time of discharge • Disability Rating Scale (DRS) at time of discharge from acute care • DRS at time of admission and discharge from in-patient rehabilitation • Glasgow Outcome Scale Extended (GOSE) at 6 months An app for GOSE is available on Google Play. Craniotomy site persistent pus discharge Cranioplasty • Post-traumatic Hydrocephalus • Chronic Subdural Hematoma (CSDH). Neurologist Seizure Rehabilitation specialist: • Spasticity • pressure sores not responding to dressings and position change. Orthopedic surgeon: • Heterotopic ossification Chest physician: • Pneumonia • Venous thromboembolism Urologist • Recurrent urinary tract infection • Complication of neurogenic bladder (urinary stone, pyelonephritis). Gastroenterologist percutaneous endoscopic gastrostomy (PEG) Psychiatrist • Depression • Psychosis • Substance abuse prior to or after injury Outcome Assessment • Glasgow Coma Scale during acute care, and at time of discharge • Disability Rating Scale (DRS) at time of discharge from acute care • DRS at time of admission and discharge from in-patient rehabilitation • Glasgow Outcome Scale Extended (GOSE) at 6 months An app for GOSE is available on Google Play.

  Aquatic Therapy Top

  Considerations in neuro-rehabilitation Top

Dipti Patil

Assistant Lecturer, ATF


“What is good for the heart is good for brain”

“Water is FUN”

  • Aquatic therapy enables to start movement training at an early rehabilitation stage, when patients face major problems with upright posture against gravity.
  • Early start is an important predictor for later stage participation
  • Water is ergonomic for the therapist, and it supports the patient.

Neuroscience behind Aquatic Therapy rehabilitation plays an important role to understand the effects of it for early recovery.

Understanding the concepts of:

  • Immersion
  • Physiology
  • Vascular
  • Cortical Activity
  • Learning
  • Memory
  • Executive Functions
  • Timing.

Various Clinical Applications


In Conclusion:

  • Water immersion prior to starting rehabilitation will promote motor cortex plasticity induction and this may help to facilitate the effects of rehabilitation
  • After immersion, the cholinergic activity increases with ability of the cerebral cortex to retain which facilitates movements on land. (Sato and Team-2021)
  • Water immersion priming (Hospital rehab) will promote long term potentiation- like plasticity induction may apply to home- based rehabilitation
  • This priming effect of Aquatic therapy will give carry over on dry land and gives measurable effects on home program.

  Case Discussion Top

  An application of aquatic therapy on autism spectrum disorder. A case study Top

Deepti Vishvakarma, Dipika Kanade

Physiotherapist, Trained Aquatic Therapist, Aquacentric, Mumbai, India

6 years old boy case study for 20 sessions explaining how aquatic therapy intervention helps to achieve care givers goals.

  Application of aquatic therapy in the management of an adolescent with cerebral palsy Top

Manasa Nair, Devashree Vora

Department of Neurology and Pediatrics, AquaCentric Therapy, Mumbai, Maharashtra, India

Youth with cerebral palsy experience limitations in their functional mobility thus restricting their participation in school and in the community. The observed incidence of Cerebral Palsy in India is estimated at around 3 cases per 1000 live births; however, the actual figure may be much higher than probable figures. In India, the majority of treatment strategies used are land based techniques heavily focussing on traditional neurorehabilitation techniques. However, Aquatic Therapy has been shown to be an effective adjunct therapy to conventional land based therapy. Youth demonstrate higher compliance with exercises in water because of the unique quality of buoyancy of water that reduces joint loading and impact. Thus, decreasing the negative influences of poor balance and poor postural control on functional mobility. This case study discusses the PT assessment and management of a 14 year old youth with spastic dystonic quadriparesis classified as GMFCS level 3 using Aquatic Therapy interventions His chief complaints are as follows: Reduced speed of indoor walking and requires continuous supervision Easily fatigued with mobility tasks Difficulty with bed mobility, sit to stand and toilet transfers Difficulty in maintaining standing balance during functional tasks Difficulty in reaching and grasping activities with B/L upper limb (R > L) His assessment was carried out and the major functional impairments were identified as follows: Difficulty in gradation of forces and excessive motor overflow to surrounding muscles Poor sustenance and co-activation of abdominal and back extensor muscles Dystonic posturing, especially observable in the upper extremity during a self initiated task Dynamic spasticity in bilateral lower extremities Immature weight shifts causing shortening of the trunk Physiotherapy goals were as follows: 1. He should be able to walk a distance of 20 meters using a tripod cane in an energy efficient manner while maintaining optimal alignment and reduced incidence of loss of balance and falls within 20 sessions 2. He should be able to perform sit to stand from a chair with hips and knees in 90-90 position without using upper limb for support and maintaining optimal alignment and using appropriate amount of force within 20 sessions 3. He should be able to maintain his balance in standing while reaching out for objects within his limits of stability while performing appropriate weight shifts for at least 3 out of 5 trials within 20 sessions He participated in a 10 week program with sessions conducted 2 times per week of 45 minute duration each. 10m walk test and 5 STS measurements were taken at baseline. Aquatic interventions were carried out in an indoor temperature controlled pool consisting of strategies using principles of Water Specific Therapy, Bad-Ragaz Ring Method and Task Specific Training which focussed on functional strengthening, inter and intra limb dissociation and balance training. Play based activities were also incorporated such as pool cricket, aqua cycling, swimming against water turbulence to improve cardiopulmonary endurance. Outcomes were measured every 10 sessions. Results obtained at the end of 20 sessions showed that there was a reduction in the time taken to perform the 5 time sit to stand test, with a baseline value of 120 seconds, which reduced to 53 seconds post the intervention. Similarly, there was also a reduction in the time taken to perform the 10 meter walk test, with a baseline value of 3 minutes 5 seconds and post intervention the value reduced to 2 minutes 32 seconds. These changes indicate there has been an improvement in the speed of performance of these activities which may be attributed to improved lower extremity strength, improved alignment and reduced energy expenditure Thus, in conclusion Aquatic Therapy is a useful rehabilitation tool to improve outcomes in functional mobility in youth presenting with Cerebral Palsy. The strategies suggested may be effective adjuncts to the conventional neurorehabilitation techniques popularly used in the management of Cerebral Palsy.

[TAG:2]Rehabilitation in Intensive [/TAG:2]

  Care Unit Top

  Early neurorehabilitation in intensive care unit Top

Dorcas Gandhi

Associate Professor and Research Fellow, Christian Medical College and Hospital, Ludhiana, India

The practice in earlier decades was for critically ill patients to be managed with deep sedation or prolonged bed rest at least in the early stages of their ICU (Intensive Care Unit) stay. Even with longstanding evidence on the deconditioning caused by prolonged bed rest and inaccessible rehabilitation services in the ICU, little has been done to implement rehabilitation practices in critical care especially in LMICs (Low and Middle Income Countries). WHY EARLY INTERVENTION In most neurological conditions it has been established that exploitation of neuroplasticity need early initiation of rehabilitation. The best example is that of stroke where the diminishing inflammation & scarring, increasing endogenous plasticity and spontaneously improving function and impairment are all augmented by rehabilitation in the acute and early subacute phases (post hyperacute phase i.e., >0-24 hours of onset). Clinical practice guidelines for rehabilitation of Spinal Cord Injuries have also strongly favoured initiation of early mobilization provided the spine and vitals are stabilised. It is thus essential to initiate early rehabilitation even in an ICU setting irrespective of whether the patient is on MV (Mechanical ventilation). AREAS OF CONCERN Immobility ICU acquired weakness – ICUAW (Mendez-Tellez et al., 2012) o Independent predictor of poor outcomes (Montero, 2001) o Prolongs weaning from MV by 2-7 times (De Jonghe B, 2004) o Prolongs ICU and hospital stay (Bastuji-Garin S, 2004) o Increased hospital mortality (Ali NA, 2008) • Chest and pulmonary system integrity o Aspiration Pneumonia o Accumulation of secretions • Maintenance of ABC (Airway, Breathing and Circulation) • Dysphagia Secondary complications o Deep Venous thrombosis o Pressure ulcers o Urinary Tract Infections o Musculoskeletal complications (tightness, contractures, deformities) o Pain Relationship between the patient's age, length of stay in the ICU and use of MV has been established. Younger patients with shorter ICU stay showed greater independence at home. More number of deaths were noted in those that were older with longer ICU stay and on MV > 7 days. MV for > 48 hours also causes increased caregiver dependence until 1 year post discharge. CURRENT REHABILITATION PRACTICES Studies have reported that most rehabilitation professionals especially in LMICs focus IC rehabilitation on individual limb movements, bedside sitting rather than on ambulation and functional training. Chest and Pulmonary care are dominated by techniques with low evidence (clapping, percussions and vibrations). Evidence based interventions like alveolar recruitment strategies, humidification, aerosol/nebulization therapies are hardly given preference. SCOPE FOR IMPROVEMENT Treatment decision making should be based a thorough assessment of patient conditions, the medications being used, status of respiratory, cardiovascular, neurological, haemodynamic, endocrine and functional systems. Researchers have developed algorithms that may guide this process for customizing patient specific rehabilitation protocols in the ICU. Links to such studies are provided here: 1) Screening algorithm to evaluate for appropriateness of early ICU rehab: Mendez-Tellez PA, Nusr R, Feldman D, Needham DM. Early Physical Rehabilitation in the ICU: A Review for the Neurohospitalist. Neurohospitalist. 2012;2 (3):96-105. 2) Clinical management algorithms for early physical activity and mobilization for 3 categories of patients: Hanekom S, Gosselink R, Dean E, van Aswegen H, Roos R, Ambrosino N, Louw Q. The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: synthesis of evidence and expert opinion and its translation into practice. Clin Rehabil. 2011 Sep; 25 (9):771-87. INTERVENTIONS A) APPROPRIATE POSITIONING • Initial specialist assessment for positioning- in acute stroke as soon as possible and where possible within 4 hours of arrival at hospital. Arm Support devices (ex: Lap Tray): for arm positioning for those at risk of shoulder subluxation Education and training to nurses, patient and caregiver: correct manual handling and positioning • Elevation of the limb when resting: individuals who are immobile to- prevention of swelling References: 1) Stroke Foundation. DRAFT Clinical Guidelines for Stroke Management 2017. Summary of Recommendations. 2) Clinical Guidelines for Stroke Management A Quick Guide for Physiotherapy. National Stroke Foundation, Australia, 2010. B) EARLY MOBILIZATION (Refer to the lecture by Karin Diserens for details) Kumar MA, Romero FG, Dharaneeswaran K. Early mobilization in neurocritical care patients. Curr Opin Crit Care. 2020 Apr; 26 (2):147-154. C) PRESSURE ULCERS For risk assessment of pressure ulcers, the Braden scale is recommended. A patient scoring low on this scale has higher risk of development of pressure ulcers. Use this link to access more details on score based treatment options and role designation: https://wtcs.pressbooks.pub/nursingfundamentals/chapter/10-5-braden-scale/• Keep skin clean and dry, check for blisters or ulceration. Patients with urine and stool incontinence using diapers should be changed and cleaned timely, as urine and stool can result in skin breakdown. • Use of air or water mattresses to reduce the occurrence of pressure sores. • Frequent changing of side at least once every two hours is recommended to be done for disabled stroke patients. Keep skin clean and dry, check for blisters or ulceration. • Patients with urine and stool incontinence using diapers should be changed and cleaned timely, as urine and stool can result in skin breakdown. Use of air or water mattresses to reduce the occurrence of pressure sores. • Frequent changing of side at least once every two hours is recommended to be done for disabled stroke patients. Refer to Winstein CJ et al., Guidelines for Adult Stroke Rehabilitation and Recovery. Stroke. 2016;47 (6): e98-e169 for clinical practice guidelines. D) DEEP VENOUS THROMBOSIS Prevention: Early mobilization (frequent ankle-toe movements, supine-cycling movements, change of position periodically) Avoid dehydration Antithrombotic drugs (LMWH) • Intermittent pneumatic compression (Class II b evidence): poor indication, only when anti-thrombotics cannot be prescribed If DVT has occurred: STOP ALL PASSIVE AND ACTIVE EXERCISES. Refer to (Hillegas E et al., Phys Ther 2016; 96 (2):143-66) for the APTA guidelines for DVT management. For risk assessment, the Well's criteria has been strongly suggested (https://www.youtube.com/watch v = JP4F5a3agXk). E) CHEST & PULMONARY CARE Main Goals Maintain or improve gaseous exchange Ensure patency of airway Prevention of secondary complications Common Barriers: Reduced consciousness Inability to protect airway Aspiration Sputum retention Hypoventilation (atelectasis) Type II respiratory failure Raised ICP & Low CPP Unstable haemodynamics Unstable spine Treatment options: Prone position, passive-ROM and CPM are safe to use in critically ill patients, suffering from brain injuries or stroke Chest percussions and vibration o Conflicting evidence on ICP (without changes in CPP) Endotracheal suctioning o Safe in the setting of adequate sedation NMES o Used in Speech rehabilitation o Role in early head injury patients limited Early mobilization o Appears to improve function and clinical outcomes Inspiratory muscle training o Facilitation of respiration Airway clearance o Assisted coughing Signs to watch for: Cushing reflex Increased BP (Physiological stress) Raised ICP Seizure (Absent/Focal) Respiratory distress Lastly, it is important to remember that every patient is unique and will respond differently to therapy. Algorithms and protocols for therapy planning need to be used as a guide with necessary customizations for each patient. Dorcas B C Gandhi Assoc. Professor, College of Physiotherapy Research Fellow and Telerehab Consultant, Dept. of Neurology Christian medical College & Hospital, Ludhiana.

  Vestibular neuromodulation: A tool for neuro-rehabilitation? Top

Mohamed Sakel1, 2, 3, 4

1Neuro-Rehabilitation Unit, 2University of Kent, 3Kent Brain Injury Forum, East Kent (UK), 4Jessore University of Science and Technology, Bangladesh

The vestibular system is a complicated, evolutionarily ancient system which detects the movement and orientation of the head. First demonstrated by Nobel Laureate Robert Barany in 1914, the vestibular system can be artificially activated by the delivery of thermal or galvanic currents in or near the adjacent external ear canal. Recent developments in solid state electronics allow these waveforms to be applied in a dose-controlled, gentle fashion suitable for not only diagnostic but potentially therapeutic use too. Unlike other forms of non-invasive neuromodulation which are anatomically imprecise and localised in effect, vestibular stimulation is endogenous in nature, activating in bottom-up fashion a number of ascending and descending neural pathways involved in motor control, interoception and egocentric perception.

Our multi-disciplinary, multi-organisational research group, based across the UK and US, and comprising neurologists, neuro-psychiatrists, physiatrists, psychologists, physicists, trials methodologists, and industrialists, seeks to determine the relevance of vestibular stimulation to clinical practice. Following a brief programme of stimulation, we have shown clinically-relevant improvements in individuals with acquired brain injury (including hemi-spatial neglect, aphasia, low awareness state), neurodegeneration (Parkinson's disease) and migraine headache. Funded by government agencies, healthcare providers and universities, we have published over a dozen peer-reviewed journal articles and given many international conference presentations. These have showcased 'first in man' proof of concept data derived from single case and small-groups studies, as well as the results of larger-scale randomised controlled trials which have since been used to obtain FDA approval.

While the multi-disciplinary make-up of our team is necessary to translate our initial academic findings into commercially available clinical solutions, such varied composition creates inevitable tensions between, on one hand, the need for the commercial partner to obtain regulatory approval and buy-in from healthcare providers and, on the other, the academic need to proceed cautiously through replication, methodological optimisation and a better understanding of mechanism of action. An allied tension relates to the degree of ownership that clinicians and academics expect to retain as their initial ideas and work are translated and applied by the commercial, downstream partner. We have found that such tensions can be overcome with open and candid conversations, and a constant reminder that, despite everyone's different contributions, all share the same motivating sentiment to improve patient well-being.

Abbreviated description:

Non-invasive neuro-modulation of the vestibular system via either electrical or thermal current is rapidly emerging as a potent intervention for the rehabilitation of brain injury. Our US/UK team has made a significant contribution to demonstrating the safety and efficacy of this novel intervention, and will present data ranging from proof-of-concept to RCT data which together has led to the first FDA approved indication for the treatment approach. We will also highlight the pros and cons of working within a diverse and international team of clinicians, academics and industrialists whose agendas often differ.

Competing interests: Dr Black is employed by Scion Neurostim LLC, one of the study partners


Professor D Wilkinson (PhD).

Professor of Psychology & Head of School, University of Kent, UK.

Doctor Robert Black, PhD

Senior VP, Scion Neurostim LLC, USA

Ms Karen Saunders, Consultant Neuro-physiotherapist, UK, Visiting Professor JUST, Bangladesh.


  1. Wilkinson D, Ade KK, Rogers LL, Attix DK, Kuchibhatla M, Slade MD, et al. Preventing episodic migraine with caloric vestibular stimulation: A randomized controlled trial. Headache 2017;57:1065-87.
  2. Vanzan S, Wilkinson D, Ferguson H, Pullicino P, Sakel M. Behavioural improvement in a minimally conscious state after caloric vestibular stimulation: Evidence from two single case studies. Clin Rehabil 2017;31:500-7.
  3. Wilkinson D, Podlewska A, Sakel M. A durable gain in motor and non-motor symptoms of Parkinson's disease following repeated caloric vestibular stimulation: A single-case study. NeuroRehabilitation 2016;38:179-82.
  4. Wilkinson D, Zubko O, Sakel M, Coulton S, Higgins T, Pullicino P. Galvanic vestibular stimulation in hemi-spatial neglect. Front Integr Neurosci 2014;8:4.
  5. Wilkinson D, Morris R, Milberg W, Sakel M. Caloric vestibular stimulation in aphasic syndrome. Front Integr Neurosci 2013;7:99.

  Symposium on Neuromuscular Disorders Top

  Up-close with Guillain–Barré syndrome: Variants, mimics and chameleons in the neurorehabilitation setting Top

Norhayati Hussein

Physiatrist, Malaysia

Guillain–Barré syndrome (GBS) is an inflammatory disease of the peripheral nervous system and is the leading global cause of acute flaccid paralysis. The prevalence of GBS is estimated to be 1–3 per 100,000 worldwide, and the disease is more common in males than in females. The GBS incidence increases with age, although all age groups can be affected. The diagnosis of Guillain–Barré syndrome is largely based on clinical features and supported by serological, electrodiagnostic, and immunological investigations. Key features are weakness, hyporeflexia/areflexia and raised CSF protein concentrations without pleocytosis. Patients with GBS classically presents with features of symmetrical sensori-motor signs in the lower extremities which gradually ascends to upper extremities and may involve the cranial nerves. Although this symmetrical paralysis of the extremities forms the classic presentation, the clinical presentation of the disease is heterogeneous, and several distinct clinical variants exist. There are several presentations of GBS variants depending on topographical involvement. The GBS variants include classic sensorimotor, pure motor, paraparetic, pharyngeal-cervical-brachial (PCB), bilateral facial palsy with paraesthesias, pure sensory, Miller-Fisher Syndrome (MFS) and Bickerstaff brainstem encephalitis. These variants may be distinct; yet often overlap and forms a continuous spectrum of discrete and overlapping syndromes. The differential diagnoses (mimics) for GBS can be broadly divided into those presenting with symmetrical extremities weakness and those presenting with brainstem signs. Miller-Fisher Syndrome (MFS) and the pharyngeal-cervical-brachial (PCB) variant of GBS are frequently mistaken for brainstem stroke, botulism or myasthenia gravis. Bickerstaff's brainstem encephalitis may be mistakenly diagnosed as Wernicke's encephalopathy and other encephalitis-related disorders. Atypical presentations (chameleons) of GBS-related disorders include paraparetic GBS, bifacial weakness with paraesthesias, acute ataxic neuropathy, acute ophthalmoparesis, acute ptosis and acute mydriasis. Though GBS affects the peripheral nervous system, clinicians may be unaware that deep tendon reflexes remain present and may even appear brisk in up to 10% of patients with GBS. This lecture will review the spectrum of GBS variants, the important differential diagnoses (mimics) for patients presenting with acute flaccid paralysis and brain stem signs; and highlights the atypical presentation (chameleons) of GBS-related disorders which may be encountered in the neurorehabilitation setting. A good appreciation of GBS variants and the common GBS mimics and chameleons is necessary for the accurate diagnosis and treatment of GBS. This will assist in realistic recovery prognostication and enable accurate planning of neurorehabilitation management.

  Symposium on Cognitive Rehabilitation Top

  The key to the hole: The role of caregivers in cognitive rehabilitation Top

A. P. Porrselvi

Founder and Cognitive Neuropsychologist, Unified Brain Health Care, Chennai Area, India

People with cognitive impairments need support and care in everyday life. They are dependent on informal care, mainly provided by spouses and adult children. According to the definition by the Family Caregiver Alliance, a family caregiver is “a person who can be any relative, partner, friend or neighbour who has a significant personal relationship with, and provides a broad range of assistance for, an older person or an adult with a chronic or disabling condition. These individuals may be primary or secondary caregivers and live with, or separately from, the person receiving care“. They are not paid. For this reason, caregivers form the backbone of the healthcare system and supporting them is an international public health priority. The role of family caregivers is important in cognitive rehabilitation but is often under appreciated. Informally, clinicians notice how the engagement of caregivers increases the therapeutic response of a patient. The caregiver is the co-therapist and forms the third vertex along with the patient and the clinician in the rehabilitation triad. Cognitive interventions provided by caregivers have shown to be associated with improvement in cognitive performance, stabilization of neuropsychiatric symptoms and certain benefits in ADL. Sustaining close emotional relationships, is a crucial factor for the person with dementia to be able to maintain sense of self. Multiple meta-analyses have repeatedly shown that people living a socially active life had a lesser risk of later being diagnosed with a dementia disease. It has been shown that a group format has benefits over individual training for healthy older adults and people with dementia benefit from group-based cognitive interventions. This suggests that cognitive rehabilitation would benefit from encouraging social interaction of patients. Such social interaction begins at home and extends into the community. When caregivers are involved and actively participate, patients benefit more in cognitive rehabilitation. There is evidence of collaborative benefits in learning and communication in couples where one partner has amnesia, and several studies have demonstrated a positive effect of spousal collaboration on memory performance in people with probable Alzheimer's dementia. Directing the cognitive interventions with involvement of caregiver is seen as most effective because of the mutual influence between the person with dementia and the caregiver. Theoretical perspectives such as “transactive memory” theory (Wegner, 1987) and distributed cognition (Harris, Barnier, Sutton, & Keil, 2014) show that, over time, a couple or family unit can become “cognitively interdependent” and start functioning together as a cognitive system that is more than the sum of its parts. This can provide huge potential for successful cognitive rehabilitation programs that are community and home-based. When one individual in the unit experiences a neurological condition such as an acquired brain injury (ABI), we need to view the system as a whole and understand how the injury impacts the unit as a whole and the interventions they require to function together for successful rehabilitation. Theories of cognitive interdependence suggest that the caregivers will be able to support and scaffold the cognitive performance of the patient and associated functional impairments. Specific scaffolding types seen in such collaborative rehabilitation are survival and stability scaffolding. Survival scaffolding is when the caregiver takes over the task at hand in order to complete it successfully. This is helpful when the patient has significant impairments. However, the patient contributes even less than they would when doing the task alone and this can lead to learned helplessness and make them dependent, losing a sense of self and purpose. This may also lead to higher caregiver stress. In everyday life, such scaffolding may be highly adaptive for tasks where it is important that they are done correctly and completely, such as remembering to take medication or completing a form. In contrast, in patients with less severe impairments, especially in the early stages of dementia, their caregivers can engage in stability scaffolding, enabling them to contribute what they can and assist in a mutually beneficial way. This form of scaffolding might increase self-worth and the quality of the family unit's interpersonal relationships. In everyday life, such stability scaffolding can be used in tasks in which accuracy and completeness are less important. Recent studies in healthy older couples have shown collaborative facilitation or benefits to cognitive performance when the caregiver and patient are involved in the cognitive interventions together. Such facilitation can occur for both non-personal stimuli (e.g., a word list learned in the laboratory) and for more personally relevant shared information (e.g., specific episodic recall of life events). Collaborative facilitation cannot occur in all units and is predicted by existing communication strategies and relationship factors. A healthy and close relationship may be associated with enhanced collaborative cognitive performance. The caveat here is, we assume that the history of the relationship to be positive, which is not always the case. Low pre-morbid quality of the relationship seems to be related to a decrease in psychological well-being of patients and caregivers, and to increased caregiver burden. Thus, this knowledge of the unit's prior and current relationship is crucial for identifying the needs and tailoring their cognitive intervention strategies. Successful collaboration in healthy older adults can produce post-collaborative benefits. These benefits seen in neurologically healthy people shows that such collaboration can be used as a cognitive rehabilitation strategy in people with impairments due to brain injury or disease. It is important to support the caregivers and family units from early stages of disease, thereby supporting the unit in 'working together' from the beginning before the negative impact of disease affects the relationship. It is important to work on the unit's sense of belonging to each other and identity. However, it may require hard work for sustaining such relationship quality. Support must be tailored for the specific needs of the unit. This contributes towards an overall improvement in well-being for people with dementia and care partners. Little research has been done to identify characteristics of caregiver engagement that benefit the patient the most. Some of the factors to be taken into consideration before devising cognitive rehabilitation programs are characteristics, knowledge and personality of the caregivers involved in the care of the patient and the interpersonal relationships in the family prior and after the illness. The priority issues according to the caregivers and perceived need from the perspective of patients and caregivers need to be addressed. The attitude and acceptance of therapy by family caregivers is important for the success of a rehabilitation program. Although caregivers want to provide caregiving because they care about their loved ones, it is also burdensome as they must cope with impaired daily functioning, changing routines, changes to the social schedule and changing roles, often with a negative impact on their health condition. Behavioural and psychological symptoms such as delusions, hallucinations, depression, and agitation are common in persons with cognitive impairments. They contribute to significant distress in patients as well as caregivers. It is essential to educate the family caregivers about relevant aspects of the diagnosis, scope of treatment, expected course, and prognosis. Cognitive rehabilitation programs targeting behavioural problems and/or ADL/IADL dependency are promising. Active training for functional activities and communication skills improves well-being of the family unit. The differentiating factor between effective rehabilitation programs and those that don't work is the level of support from trained health professionals. Regular supervision with weekly feedback that is provided to the caregivers on successes and problems in implementing cognitive interventions, as well as time spent on strategies and activities can make a difference in ensuring the efficacy of the intervention provided by the caregiver in home-based rehabilitation. Efforts must be made to increase community awareness that the earlier the rehabilitation program is implemented, the more effective it will be, irrespective of the neurological disease and its nature.

  Cardiac autonomic dysfunction in neurological disorders Top

T. N. Sathyaprabha

Department of Neurophysiology, NIMHANS, Bengaluru, Karnataka, India

The Autonomic nervous system (ANS), a division of the Peripheral nervous system, is an extensive neural network that adjusts the functions of various organs to changing internal and external conditions, consequently maintaining homeostatic functions essential to life. Disturbance of the autonomic function (Autonomic dysfunction-AD) is often proclaimed as an early sign for many neurological disorders, including neurodegenerative, vascular brain diseases, spinal cord injury, and peripheral neuropathies.[1] AD leads to a variety of symptoms that could impact each organ system of the body. The central autonomic network (CAN), which controls the autonomic flow spread over the whole of the neuraxis, including the anterior cingulate cortex (ACC), anterior insula, hypothalamus, amygdala, periaqueductal gray matter, parabrachial nucleus, and several regions of the medulla. The most vital cortical area that controls both sympathetic and parasympathetic outflow for cardiovascular regulation is the insular cortex. Most neurodegenerative diseases affect this region and disrupt cardiovascular regulation.[2]

Assessment of the cardiac autonomic reflexes plays a significant role in evaluating the autonomic tone in neurological disorders. Non-invasive techniques like monitoring subtle changes in electrocardiogram (ECG), heart rate (HR), and blood pressure (BP) are currently being used to give a wealth of information on subtle perturbations in the regulatory mechanism. The HR and BP signals can be plotted during rest and in response to particular provocative manoeuvres. A standard battery of tests based on Ewing and Clarke's protocol has been used in the laboratory setting. That includes measurement of HR and BP during deep breathing, the Valsalva maneuver, standing, and isometric exercise.[3] Other challenges to assess the function of ANS include cold pressor test, tilt test, coughing, carotid sinus massage, exercise, mental stress, cold stimuli, apneic facial immersion, and infusion of vaso-active pharmacological agents.[4] Responses in HR and BP has also been investigated by means of heart rate variability (HRV) using continuous Lead II electrocardiogram (ECG), blood pressure variability (BPV) from beat to beat BP recordings, and baroreflex sensitivity (BRS) derived from HR and BP variabilities.[5],[6]

Disorders such as epilepsy, Parkinson's disease, stroke, migraine, multiple system atrophy, and spinocerebellar ataxias are associated with altered cardiac autonomic regulation. Particularly in MSA and PD, autonomic dysfunction appears before motor symptom onset. The recognition and quantitative analysis of these symptoms can promote early diagnosis and initiation of treatment and identify populations at risk. This impairment of autonomic function can reduce patients' quality of life regardless of the duration of the disease. Anomalous autonomic discharge is also a crucial underlying mechanism for sudden unexpected death in epilepsy (SUDEP). Owing to its impact, early diagnosis of this autonomic dysfunction in patients with neurological disorders can prevent the elevated risk of cardiovascular events and mortality.[1],[7] Autonomic involvement in these neurological conditions could be acute as in stroke, anoxia, subarachnoid hemorrhage, and traumatic brain or spinal cord injury; sub-acute as in autoimmune and paraneoplastic autonomic neuro/ganglionopathy; or chronic and progressive as in neurodegenerative conditions like synucleopathies, multiple system atrophy, and Parkinson's disease. The clinical features of this autonomic dysregulation involve various visceral organs innervated by ANS and may result in symptoms such as orthostatic intolerance, changes in patterns of sweating, pupillary abnormalities, intolerance to light, dryness of eyes and mouth, bladder, sexual dysfunctions, and gastrointestinal complaints due to secretomotor abnormalities like gastroparesis and constipation.[8] In addition, cardiac autonomic dysregulation is a significant factor in sudden unexplained death in epilepsy (SUDEP).[9] Furthermore, the AD in neurological conditions could affect components of the CAN. Parasympathetic dysfunction appeared to be the earliest manifestation of dysautonomia in disorders affecting the CAN is possibly due to the involvement of preganglionic vagal fibers in the ventral Nucleus ambiguus and dorsal vagal motor nuclei. Also, patients with autosomal dominant spinocerebellar ataxias (SCA's) suffer from degeneration of central autonomic neurons in the rostral fastigial nucleus of the cerebellum, which actively participates in orthostatic homeostasis and other autonomous control mechanisms. Cardiac dysautonomia was found to be present in all types of SCA's with the degree of severity correlating negatively to the duration of the illness and not to its genetic markers (CAG repeat length).

While cardiac autonomic dysfunction is a part of the disease either early on or during disease progression, we at NIMHANS have also observed that the drugs used to treat neurological conditions may influence autonomic functions. Carbamazepine, used in epilepsy care, dopaminergic agents used to manage Parkinson's disease, significantly alter cardiac autonomic dysfunction.[10],[11] Furthermore, studies from our laboratory have shown that alternative medicines and therapies like Ayurveda and Yoga could modulate cardiac autonomic dysfunction, tilting the balance favoring vagal influence.[12],[13],[14]

Yoga, an ancient Indian technique of restoring homeostasis of body-mind functioning, helps maintain good health and manage diverse disease conditions. Various clinical conditions associated with autonomic dysfunction, such as hypertension, diabetes, anxiety, depression, migraine, epilepsy, and pain, improve with regular yoga practice. Such positive effects may help to manage or avert secondary cardiac morbidities in neurological diseases. With this background, the current presentation will deal with cardiovascular autonomic dysfunction in neurological disorders, understanding the interaction between neurological and cardiovascular control. It will also look at the possible effect of specific medication and alternative therapies like Yoga in the modulation of cardiac autonomic dysfunction in selective neurological illnesses.


Cardiac autonomic dysfunction in majority of neurological disorders are associated with increased sympathetic and decreased parasympathetic activity. However, the mechanisms responsible for these changes are poorly understood. This presentation is unique to comprehensively understand the role of the autonomic nervous system in neurological disorders and understand the possible influence of drugs and therapy on this autonomic dysfunction. Our studies at NIMHANS have demonstrated that cardiovascular autonomic function is disturbed in neurological disorders, including epilepsy, spinocerebellar ataxias, and Parkinson's disease. This change in cardiac autonomic function was found in drug naïve epilepsy and chronic refractory epilepsy. We have also demonstrated the effect of certain medications on AD and the use of alternative therapies like Yoga in the modulation of cardiac autonomic dysfunction in select neurological illnesses. All these outcomes obtained from our study at NIMHANS have shown that the autonomic nervous system has an immense role in maintaining normal homeostasis and the initiation and prognosis of different neurological conditions. Hence identifying this cardiac autonomic dysfunction at an early phase of the disease helps to understand the disease in a better way and to design a proper treatment protocol. This ANS assessment also can be used as a prognostic tool for various health ailments.


  1. Bassi A, Bozzali M. Potential interactions between the autonomic nervous system and higher level functions in neurological and neuropsychiatric conditions. Front Neurol 2015;6:182.
  2. Li DP, Li YL, Li J, Wang S. Neural mechanisms of autonomic dysfunction in neurological diseases. Neural Plast 2017;2017:2050191.
  3. Mativo P, Anjum J, Pradhan C, Sathyaprabha TN, Raju TR, Satishchandra P. Study of cardiac autonomic function in drug-naïve, newly diagnosed epilepsy patients. Epileptic Disord 2010;12:212-6.
  4. Pascoe MK, Low PA, Windebank AJ, Litchy WJ. Subacute diabetic proximal neuropathy. Mayo Clin Proc 1997;72:1123-32.
  5. Stevens SL, Wood S, Koshiaris C, Law K, Glasziou P, Stevens RJ, et al. Blood pressure variability and cardiovascular disease: Systematic review and meta-analysis. BMJ 2016;354:i4098.
  6. La Rovere MT, Pinna GD, Maestri R, Sleight P. Clinical value of baroreflex sensitivity. Neth Heart J 2013;21:61-3.
  7. Fanciulli A, Strano S, Colosimo C, Caltagirone C, Spalletta G, Pontieri FE. The potential prognostic role of cardiovascular autonomic failure in α-synucleinopathies. Eur J Neurol 2013;20:231-5.
  8. Palma JA, Benarroch EE. Neural control of the heart: Recent concepts and clinical correlations. Neurology 2014;83:261-71.
  9. Bermeo-Ovalle AC, Kennedy JD, Schuele SU. Cardiac and autonomic mechanisms contributing to SUDEP. J Clin Neurophysiol 2015;32:21-9.
  10. Sathyaprabha TN, Koot LA, Hermans BH, Adoor M, Sinha S, Kramer BW, et al. Effects of chronic carbamazepine treatment on the ECG in patients with focal seizures. Clin Drug Investig 2018;38:845-51.
  11. Sriranjini SJ, Ganesan M, Datta K, Pal PK, Sathyaprabha TN. Effect of a single dose of standard levodopa on cardiac autonomic function in Parkinson's disease. Neurol India 2011;59:659-63.
  12. Sathyaprabha TN, Satishchandra P, Pradhan C, Sinha S, Kaveri B, Thennarasu K, et al. Modulation of cardiac autonomic balance with adjuvant yoga therapy in patients with refractory epilepsy. Epilepsy Behav 2008;12:245-52.
  13. Kishore RK, Abhishekh HA, Udupa K, Thirthalli J, Lavekar GS, Gangadhar BN, et al. Evaluation of the influence of ayurvedic formulation (Ayushman-15) on psychopathology, heart rate variability and stress hormonal level in major depression (Vishada). Asian J Psychiatr 2014;12:100-7.
  14. Jaideep SS, Nagaraja D, Pal PK, Sudhakara D, Talakad SN. Modulation of cardiac autonomic dysfunction in ischemic stroke following ayurveda (Indian System of Medicine) treatment. Evid Based Complement Alternat Med 2014;2014:634695.

  Symposium on Neuromuscular Disorders Top

  Managing chronic fatigue Top

Shiv Lal Yadav

Professor, AIIMS, New Delhi, India

The term “neurasthenia”, first used in 1869 means “lack of nerve force“. Neurasthenia, a diagnosis characterized by chronic fatigue, was defined by George Beard inthe best-selling book American Nervousness.Chronic fatigue is one of the most underestimated yet debilitating symptoms inneuromuscular disease. Chronic fatigue is mostly seen in various neurological disorders likepost stroke, post-poliomyelitis, multiple sclerosis, in chronic fatigue syndrome, in manyneuromuscular junction diseases etc., Chronic fatigue is defined when fatigue lasts for morethan six months. In central, peripheral, and autonomic nervous systems diseases centralfatigue is seen and peripheral fatigue is seen in many neuromuscular junction disorders andmetabolic diseases leading to failure to maintain the force of muscle contraction. In NMDscause of fatigue development are cardiopulmonary impairments, deconditioning, loss ofmobility, pain, depression and others co-morbidities etc., Apart from neuromuscular disorders (NMD), currently chronic fatigue related to cancer and post-COVID syndromes ('longCOVID') are topics of interest. Post-COVID-19 fatigue is defined as the decrease in physicaland/or mental performance that results from changes in central, psychological, and/orperipheral factors due to the COVID-19. Management of chronic fatigue is mainly symptomatic and rehabilitative.The chronic fatigue syndrome (CFS) is characterized by intense permanent fatigueof unknown cause, and limits the patient's functional capacity, producing various degrees of disability. There are multiple theories exist in causation of CFS like genetics, infections, neuro-inflammation, alteration in immunity etc., Diagnostic Criteria for CFS (2015) states that it requires the presence of thefollowing three symptoms for more than six months as well as the intensity of the symptomsshould be moderate or severe for at least 50% of the time. The three main symptoms include: Fatigue: A noticeable decrease or impairment in a patient's ability to engage in activities thatthey would enjoy before the onset of the illness. This impairment continues for more than sixmonths and is associated with new-onset severe fatigue unrelated to exertion and not relievedby rest. Post-exertional malaise: Patients experience worsening symptoms and function afterexposure to physical or cognitive stressors, which they previously well tolerated.Unrefreshing sleep: patients feel that they are tired after a night's sleep.Criterion fulfilment for diagnosis requires the three above-stated symptoms, plus one of theadditional below-mentioned symptoms. Cognitive impairment: Problems with the thought or executive function worsened by exertion, effort, stress, or time pressure. Orthostatic intolerance: Worsening of symptoms upon assuming and maintaining an upright posture. Symptoms are improved, although not necessarily abolished, by lying back down orelevating the feet.Diagnosis of chronic fatigue is of utmost importance because chronic fatigue can be related to psychiatric and functional disorder or it may be due organic cause primarily due to brain or other system involvement There are numerous scales to measure fatigue. An example of a well known fatigue measure is the Fatigue Severity Scale (FSS); it is composed of nine items. There is also a 14-item Fatigue Scale (Chalder, 1993). A 54-item Profile of Fatigue-Related Symptoms (PFRS) was developed to measure CFS symptomatology. A recently developed one is ME/CFS Fatigue Types Questionnaire (MFTQ), a 22-item scale designed to measure the duration, severity and frequency of different fatigue-related sensations and symptoms. Short Form-36(SF-36), Multidimensional Assessment of Fatigue (MAF) scales, Multidimensional Fatigue Inventory (MFI), Piper Fatigue Scale (PFS), and the Visual Analog Scale (VAS) of fatigueare also used to measure fatigue.Management broadly includes non-pharmacological and pharmacological approaches. Non-pharmacological approaches include Cognitive-Behavioural Therapy (CBT), Graded Exercise Therapy (GET), Adaptive Pacing Therapy (APT), activitymodifications, programmed physical exercise, control and coping with disease-associatedstress, and cognitive restructuring etc., A regular pattern of activity is generally encouraged in all patients: the amountundertaken should be modest, spread throughout the day, with greater emphasis on regularitynot on level of performance. Aerobic exercise (gentle and low-impact) especially helps tomaintain cardiorespiratory fitness and also it has a beneficial effect on mood, psychological well-being, appetite, and sleep, in addition, it lowers the risk of metabolic syndrome. Pool therapy is often an ideal way for patients with NMD to do aerobic exercise, as simple aswalking in the water, with the water at mid-chest height. This is best done in a therapy poolwith a flat, uniform depth floor that is heated to 92F to 95F. The warmth of the water willhelp reduce spasticity and facilitate movement.Excessive physical activity has a detrimental effect on fatigue and level of physicalendurance, probably because of an accelerated rate of decline in function of the surviving motor units which is seen in post-poliomyelitis patients. This is the reason why many a times submaximal non-fatigable exercises are advised for many myopathies like Duchenne Muscular Dystrophy (DMD).During the CBT sessions, the therapist emphasizes the role of thought process and itsimpact on the patient's actions and feelings, as well as recognizes behaviours that cause themto feel more tired and hence minimize them. Multiple trials, as well as Cochrane reviews, showed the positive benefits of CBT on improving fatigue, mood, and post-exertional malaisein both adolescent and adult patients. GET involves a supervised, gradual increase of physicalactivity intensity and duration. Pharmacological options are pain medication (NSAIDS), Tricyclic Antidepressants, Selective Serotonin Reuptake Inhibitors (SSRI) and Serotonin-Norepinephrine ReuptakeInhibitors (SNRI), antiviral therapy (nucleotide analogue inhibitors) mainly in cases of viralcausation, immunoglobulins, and corticosteroids. There are few complementary andalternative medicines like essential fatty acids, magnesium, acetyl-l-carnitine, vitamin B12, and antioxidants also being used. Some newer agents are in research like Rintatolimod, Rituximab, and Faecal Microbiota Transplantation. For TCAs it takes mostly 3-4 weeks for symptoms relief. Shorter acting benzodiazepines could also be effective for nocturnal myoclonus and periodic limbmovements during sleep in central fatigue. Aminopyridines (also used for treatment of Lambert-Eaton myasthenic syndrome) are effective in fatigue associated with multiplesclerosis. Amantadine, originally developed as an antiviral for the influenza virus, is probably the most effective pharmacological treatment for fatigue with multiple sclerosis. Pemoline, acentrally active sympathomimetic, has been recommended for fatigue in multiple sclerosis.Methylphenidate has been used occasionally in fatigued patients with multiple sclerosis andmultiple system atrophy. Modafinil is a central stimulant drug and is the first line of treatmentfor excessive daytime sleepiness and in narcolepsy. Many of the NMDs, particularly the mitochondrial myopathies, share similar final common pathways of cellular dysfunction that may be favourably influenced by Creatine Monohydrate (CrM) supplementation.Apart from this treatment options, especially in NMDs, specific areas should bead dressed for proper management. In NMDs cardiopulmonary impairments must be treated adequately since such impairments itself cause chronic fatigue. Chronic fatigue substantially impairs the quality of life of a person; hence fruitful rehabilitative approaches are essential to minimize the disability. Future research should focus on better understanding of the pathophysiological pathways of fatigue in NMD, with agoal of planning better treatment options that will alleviate symptoms, improve quality of lifeand maximize physical and psychological functioning.

  Symposium on Stroke Rehab Top

  Dysphagia rehabilitation after stroke Top

Akila Rajappa

Department of Communication Sciences and Disorders, College of Health Sciences, East Stroudsburg University of Pennsylvania, East Stroudsburg, Pennsylvania, USA

Presentation Format: WILL PRESENT LIVE

Swallowing disorders known as dysphagia affects millions worldwide can be caused due to many disease conditions. Stroke is a common cause of dysphagia that can result in devastating consequences such as malnutrition, dehydration, aspiration pneumonia, decreased rehabilitation potential, increased health care costs, and decreased quality of life. Early identification and intervention of post stroke dysphagia is a medical priority to prevent these adversities. Dysphagia treatment for many years has relied on utilization of compensatory approaches. Compensatory dysphagia management approaches such as provision of mechanically altered diets, feeding tubes and management strategies and/or maneuvers are frequently used in dysphagia treatment as it allows for immediate reduction in risks and is good for short term. However, compensatory management strategies reinforce underlying swallowing impairment. Clinical research data demonstrate that although compensatory management strategies are effective at limiting aspiration but not at improving swallowing. Feeding tubes do not reduce aspiration nor occurrence of aspiration pneumonia. Feeding strategies (i.e., feeding tubes, diet modifications etc.) do not improve hydration (Langmore et al. 1998; Martin et al., 1994). Dysphagia treatment should be directed at the physiological or anatomical disorder, rather than at the symptoms alone. Current research demonstrates that dysphagia rehabilitation improves the sensorimotor control systems that are involved in swallowing and are designed to change/improve swallowing physiology through neuromuscular underpinnings serving the oropharynx. This talk will address the pathophysiology of dysphagia caused due to stroke, diagnostic accuracy and specificity for post stroke dysphagia and discuss in detail the evidence-based practice and upcoming trends pertaining to dysphagia rehabilitation post stroke. Emphasis will be on utilization of foundation principles underlying dysphagia rehabilitation such as neuroplasticity, motor learning, exercise physiology and strength/skill-based approaches. Discussion about peripheral and central stimulation treatment paradigms for dysphagia rehabilitation post stroke will also be covered.

  Clinical Trial governance and conduct – Ethics, guidelines, trial registration and reporting Top

Farooq Azam Rathore1,2

1Department of Rehabilitation Medicine, PNS Shifa Hospital, Karachi, Pakistan, 2Orthotist & Prosthetist, Department of Rehabilitation Medicine, PNS Shifa Hospital, Karachi, Pakistan

”To maximise the benefit to society, you need to not just do research, but do it well”.[1]

Doug Altman (1948-2018), statistician, researcher

The World Health Organization (WHO) defines clinical trial as 'any research study that prospectively assigns human participants or groups of humans to one or more health-related interventions to evaluate the effects on health outcomes. Interventions include but are not restricted to drugs, cells and other biological products, surgical procedures, radiological procedures, devices, behavioural treatments, process-of-care changes, preventive care, etc.”[2]

The history of human research is thousands of years old.[3] It has progressed from dietary therapy of legumes and lemons in the Roman era to scurvy trials of James Lind and battle filed experiments of Ambroise Parè to the human experiments performed by the Nazi physicians during world war II.[1] However, at that time there was no formal mechanism for any institutional oversight, safeguard for the research participants or concept of an informed consent. This resulted in many events which would today be classified as breach of human research ethics, research misconduct or violation of basic human rights. Some of them include the pre-World War II eugenics movement supported by many prominent scientist and physicians of that time,[4] U.S. government-sponsored radiation research on humans (1945-1975),[5],[6] Japan's medical experimentations on prisoners of war (POW) and medical field testing on Chinese civilians (1941-1943)[7],[8] German Nazi's human experimentation on Jews and other POW resulting in the death of a large number of the research subjects,[9],[10] Tuskegee Syphilis study,[11] and Milgram obedience experiments.[12]

Over the years, clinical research has become more formal and organized. Human research ethics principles have been identified and many guidelines published across the globe. There is an emphasis on the increased transparency, ethical conduct of research, protection for the participants and institutional oversight. Some remarkable work in the field of research ethics has been done in the last five decades.[13] The foundations for ethics concerning human research were laid down in the 1947 Nuremberg Code and the 1964 Declaration of Helsinki.[14] Nuremberg code for the first time stressed on the importance of voluntary participation in research. The declaration of Helsinki is based on the report “Ethical Principles for Medical Research Involving Human Subjects”. It has undergone multiple and extensive revisions with the last revision being in 2013.[15] In 1979, The National Commission for the Protection of Human Subjects in Biomedical and Behavioral Research, USA published The Belmont Report: Principles of Ethical Research on Human Subjects. The Report provides the conceptual foundation for a major revision of the U.S. research regulations in 1981.[13] It discusses the issue of informed consent for patient recruitment in research, assessment of risks and benefits for the research participants and ensuring reasonable, non-exploitative, and well-considered procedures are administered fairly.

Nowadays a full-informed consent without any coercion or exploitation is a mandatory requirement to conduct a clinical trial involving human subjects. Other ethical aspects that need attention are use of placebo, risk analysis, post-trial care and the issue of compensation.

Prospective registration of a clinical trial particularly it is a randomized controlled trial (RCT) is a mandatory requirement for publication as outlined by the International Committee of Medical Journal Editors (ICMJE).[16] There are at present more than 20 clinical trial registries from different parts of the world. Some of them include the United States' ClinicalTrials.gov, United Kingdoms' ISRCTN registry, Australia and New Zealand's (ANZCTR), Chinese Clinical Trial Registry (ChiCTR), Clinical Trials Registry - India (CTRI), EU Clinical Trials Register (EU-CTR), German Clinical Trials Register (DRKS), Iranian Registry of Clinical Trials (IRCT) and Pan African Clinical Trial Registry (PACTR).

The reporting of the clinical trial should follow certain guidelines called reporting guidelines. A reporting guideline is defined as “a checklist, flow diagram, or structured text to guide authors in reporting a specific type of research, developed using explicit methodology.”[17] A reporting guideline is a simple, structured tool for health researchers to use while writing manuscripts. A reporting guideline provides a minimum list of information needed to ensure a manuscript can be understood by a reader, replicated by a researcher, used by a doctor to make a clinical decision, and included in a systematic review. The recommended reporting guideline for an RCT is Consolidated Standards of Reporting Trials (CONSORT). CONSORT is an evidence-based, minimum set of recommendations for reporting randomized trials. It offers a standard way for authors to prepare reports of trial findings, facilitating their complete and transparent reporting, and aiding their critical appraisal and interpretation. The CONSORT Statement comprises a 25-item checklist and a flow diagram. The checklist items focus on reporting how the trial was designed, analyzed, and interpreted; the flow diagram displays the progress of all participants through the trial.

It is important that clinical trial should be conducted in a transparent manner with an appropriate administrative and ethical review committee oversight. In addition, emphasis should be made on following the ethical principles and adhering to the appropriate guidelines and standards of reporting. This will ensure that the research is ethical and beneficial both to the society and the participants resulting in data that can be used to make a positive difference in patients' lives.


  1. Bahor Z. Remembering Doug Altman. Available from: https://blogs.bmj.com/openscience/2018/07/09/remembering- doug-altman/. [Last accessed on 2021 Jul 25].
  2. University of California. San Francisco. Available from: https://hub.ucsf.edu/clinicaltrialsgov-definition-clinical-trial. [Last accessed on 2021 Jul 20].
  3. Baron JH. Evolution of clinical research: A history before and beyond James Lind. Perspect Clin Res 2012;3:149.
  4. Spiegel AM. The Jeremiah Metzger lecture: A brief history of eugenics in America: Implications for medicine in the 21ST century. Trans Am Clin Climatol Assoc 2019;130:216-34.
  5. McCally M, Cassel C, Kimball DG. U.S. government-sponsored radiation research on humans 1945-1975. Med Glob Surviv 1994;1:4-17.
  6. Schneider K. Secret nuclear research on people comes to light. N Y Times Web 1993;A1, B11.
  7. Strous RD, Zivotofsky AZ. Looking to the future from the past: Take home lessons from Japanese World War II medical atrocities. Am J Bioeth 2015;15:59-61.
  8. Dahlby T. Japan's germ warriors: Plumbing the horrors of 'Devil's Brigade.' Washington Post 1983;A1, A25.
  9. Oehler-Klein S, Preuss D, Roelcke V. The use of executed Nazi victims in anatomy: Findings from the institute of anatomy at Gießen University, pre- and post-1945. Ann Anat 2012;194:293-7.
  10. Miles SH. The diptych: Nazi and Japanese bioscience war crimes. Am J Bioeth 2015;15:52-4.
  11. Katz RV, Warren RC Eds. The search for the legacy of the USPHS syphilis study at Tuskegee. Lexington 2011. J Natl Med Assoc Summer 2014;106:73-4.
  12. Cave E, Holm S. Milgram and Tuskegee – Paradigm research projects in bioethics. Health Care Anal 2003;11:27-40.
  13. Resnik DB. Research Ethics Timeline. Available from: https://www.niehs.nih.gov/research/resources/bioethics/timeline/index.cfm. [Last accessed on 2021 Jul 24].
  14. University of Nevada, Los Vegas. History of Research Ethics. Available from: https://www.wma.net/what-we-do/medical-ethics/declaration-of-helsinki/. [Last accessed on 2021 Jul 24].
  15. World Medical Association. Medical Research Involving Human Subjects. Available from: https://www.unlv.edu/research/ORI-HSR/history-ethics. [Last accessed on 2021 Jul 24].
  16. 16ICMJE. Available from: http://www.icmje.org/about-icmje/faqs/clinical-trials-registration/. [Last accessed on 2021 Jul 24].
  17. EQUATOR Network. What is a Reporting Guideline? Available from: https://www.equator-network.org/about-us/what-is-a-reporting-guideline/. [Last accessed on 2021 Jul 25]

  Rehabilitation in the home: An Australian prespective Top

Fary Khan, Bhasker Amatya1

Department of Rehabilitation, Royal Melbourne Hospital, 1Department of Medicine, University of Melbourne, Parkville, Victoria, Australia

Rehabilitation is an essential component across all levels of the healthcare system. It is a pillar for sustainable development, contributing to health, economic and social development.[1] Rehabilitation needs have grown significantly worldwide, due to current global health and demographic trends, and the high prevalence of disability in the world population.[2] An estimated 2.41 billion individuals globally have conditions that would benefit from rehabilitation input, this equates to at least one in every three people requiring rehabilitation at some point during their disease trajectory or injury course.[3] Further, the current COVID-19 pandemic has created a range of additional challenges testing resilience of many healthcare systems and vulnerabilities at all levels (acute, sub-acute, community, individuals) on the global stage.[4] This brings numerous operational and organizational challenges to the rehabilitation services, specifically on inpatient caseload management, signifying the need for new patient care models and reshaping of services to deliver comprehensive care effectively. Various alternative sustainable methods of service delivery have been considered including, tele-rehabilitation, rehabilitation in home, community rehabilitation, etc.

The Rehabilitation Medicine Department at the Royal Melbourne Hospital in Victoria, Australia is one of the leading organizations to initiate the 'Rehabilitation in the Home (RITH)' program since 2017. The program is led by a treating rehabilitation physician. It is a bed- substitution model of service delivery, providing evidence-based rehabilitation practice in the comfort of a person's own home, or other suitable environment. Standard care is delivered at home to patients who are medically stable enough to be at home and therefore do not require frequent monitoring. The rehabilitation treatment is patient-focused, taking into consideration the psychological, physical and environmental needs of the patient and not influenced by the funding models. It is voluntary, provided free of charge under Medicare in Australia for permanent residents and citizens. Patients are regarded as inpatients and receive similar comprehensive treatment that they would have received had they been in an inpatient hospital bed.

The service delivery is coordinated with primary care and community based services. In June 2019, '[email protected] Subacute care', which included the RITH combined with the '[email protected] Acute care' service under a single banner – '[email protected]' to provide both acute and subacute care for patients in their home environment.[5] The [email protected] team works closely with the referring patient's medical unit, patient (carers/family), and community healthcare providers to develop a realistic plan of treatment in the patient's home. The [email protected] Subacute has admitted 300 patients in a year since its launch in 2019 and now has expanded to 15 beds.[6] The service includes:

  • review by a multidisciplinary team including physician, nursing, physiotherapy, occupational therapy, dietician, social worker and speech therapy as required
  • daily home based visits over a 2 to 3 weeks length of stay
  • patient centered, goal-based therapy
  • Geriatric Evaluation and Management (GEM)
  • rehabilitation following fracture, orthopedic surgery or acute medical illness/event
  • falls assessment and management
  • reconditioning following an acute exacerbation of a chronic illness

The service delivers safe, timely, effective, person-centered care using technology and innovative models of care. It aims to:

- increase capacity for the most acutely unwell and complex patients to be treated within the hospital walls

- Improves outcomes and recovery at home against a range of clinical markers including symptoms, function, psychological issues, etc.

- maximizes patient safety and support efficient care delivery

- improves efficient utilization of patient and/or carer's time, traveling costs

- prevents unnecessary admission/readmission and more efficient utilization of beds within hospitals

- more capacity building for staff

- improve patient satisfaction

- reduce the cost to the hospital (lower cost than inpatient rehabilitation care)

- reduce waitlists to improve patient transition and experience

- better networks and collaboration in the community

Details of the evaluation of the [email protected] service using a Strength, Weakness, Opportunity, and Threat (SWOT) analysis are tabulated below in [Table 1].
Table 1

Click here to view


  1. Cieza A. Rehabilitation the health strategy of the 21st century, really? Arch Phys Med Rehabil 2019;100:2212-4.
  2. Stucki G, Bickenbach J, Gutenbrunner C, Melvin J. Rehabilitation: The health strategy of the 21st century. J Rehabil Med 2018;50:309-16.
  3. Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the global burden of disease study 2019: A systematic analysis for the global burden of disease study 2019. Lancet 2021;396:2006-17.
  4. Amatya B, Khan F. Rehabilitation response in pandemics. Am J Phys Med Rehabil 2020;99:663-8.
  5. Royal Melbourne Hospital. [email protected]; 2021. Available from: https://www.thermh.org.au/health-professionals/clinical-services/community-services/rmh-at-home. [Last accessed on 2021 Jul 06].
  6. Island L. [email protected] Improvement Summary (Standard Action No.: 5). Melbourne: Royal Melbourne Hospital; 2020.

  Immersive virtual reality for memory rehabilitation: Is it the way forward? Top

Furqan Ahmed Siddiqi

Orthotist & Prosthetist, Foundation University Institute of Rehabilitation Sciences (FUIRS), Foundation University Islamabad, Defense Avenue, DHA Phase-I, Rawalpindi, Islamabad, Pakistan E-mail: [email protected]

Virtual reality (VR) is defined by Lombard & Ditton, 1997, as, “digitally rendered complex 3D representation of the virtual world enabling interaction with computing environment and associated with the feeling of being present in the virtual environments”.[1] Currently, virtual reality is used in for the purpose of diagnosis as well as treatment in persons with cognitive impairments.[2] The clinical utilization of virtual reality presents recreations of real life situations and setting to discern and amend the behavior and conduct of the patient in environmentally valid settings.[3] Memory impairments are a common occurrence, associated with numerous conditions and disorders, comprising a broad spectrum of diseases as well, including but not limited to schizophrenia, depression, bipolar disorder, obsessive-compulsive disorder, Alzheimer disease Parkinson disease, Huntington disease, multiple sclerosis, stroke and even conditions such as acquired immunodeficiency syndrome (AIDS), making memory rehabilitation an integral and import part of the management and rehabilitation of such patients.[3] Evidence has shown, that in addition to pathological changes, memory deterioration and decay is also associated with the normal healthy aging processes,[4] further signifying the importance of memory rehabilitation.[3] Moreover, memory decline and impairments may symbolize an important objective for cognitive training in the geriatric rehabilitation as well as cognitive rehabilitation in the aforementioned mental and neurological disorders.[3]

As mentioned, cognitive training is an important part of the management of mental and neurological disorders and characterizes the process of recurrent cognitive exercises and interventions envisioned to augment the cognitive functions of the patients[5] based on neuroplasticity principles.[6] The expression 'cognitive rehabilitation' is used in the clinical setting to define training and management focused at the restoration of impaired cognitive functions.[3] Currently, modern technology is being used for the purpose of memory rehabilitation in the form of computerized cognitive training. Numerous studies have been published investigating the the effectiveness of computerized cognitive training in different mental and neurological disorders.[6] Computerized cognitive training allows the specific and repetitive exhibition of the stimuli and characteristically applies straightforward tasks concentrating on one cognitive domain. Recent meta-analyses' published, have focused on the effectiveness of computer assisted rehabilitation [7],[8],[9] demonstrating a minor to modest effect on memory function, endorsing equivalent efficacy to the conventional paper-pencil approach.[3] Regarding complex three dimensional virtual environments, existing systematic reviews have summarized research studies focusing on cognitive rehabilitation in patients of traumatic brain injury, stroke, and multiple sclerosis demonstrating improvement in balance, upper limb functions and in cognitive function.[3] Furthermore, recent systematic reviews have also supported the utility of virtual environment in cognitive rehabilitation in both healthy and pathological aging.[9] The advantage of virtual environment in contrast to the traditional motor or cognitive interventions has been found to be associated with an added encouraging and affirmative attitude along with augmented motivation towards training.[8] La Corte et al. arguments that the results of rehabilitation carried out via virtual reality training stay preliminary and provide data regarding feasibility but not enough data about the effectiveness.[10]

Regarding immersion in virtual reality, immersion is defined as the ability of the virtual system to support sensorimotor contingencies. Immersion is a constituent of the technology used and is an integral factor in the application of virtual reality systems.[11] Higher quality of the system results in a greater level of immersion, and higher immersion has been found to be linked with an increased level sensation of being within the virtual environment.[12] The experience of immersion during cognitive training can assist the transference of learned abilities to real life circumstances, and also incorporates real world situations and encounters in virtual reality while preserving control over offered stimulus, leading to the ecological validity of cognitive rehabilitation.[3] This is further supported by findings of previous studies suggesting that virtual simulations of daily life activities can better forecast real world functioning than regular neuropsychological measures.[13]

The most commonly used “immersive” technology to present a virtual environment is via the use of head mounted displays.[3] Moreover, interaction with virtual environment is usually enabled with special controllers or hand trackers.[13] It is reasoned that both immersive and non-immersive VR have certain advantages and disadvantages for their use in cognitive rehabilitation. Regarding the advantages of immersive over non immersive virtual reality, despite the theoretical advantages of immersive virtual reality and its growing practice in cognitive rehabilitation, very little is known about its benefits over the more affordable desktop applications with lower levels of immersion.[12] The potential of immersive virtual environments has been described by numerous studies[14] and also in a meta-analysis conducted by by Hill et al.[8] Up to now there are only 2 studies that have compared the effectiveness of immersive and non-immersive virtual reality approaches in terms of cognitive rehabilitation.[15],[16] both of which were not found to be conclusive. Furthermore, it is has been described that the application of immersive virtual reality in memory assessment can result in worse performance, which is perhaps because of the augmented cognitive load.[3]

The existing research has shown only a minor additional effect of the complex virtual reality environments on memory rehabilitation in contrast to the standard.[3] Plechata A et al. in a systematic review, debates that a few studies using immersive virtual reality does not permit an evaluation of the possible advantageous value of immersive virtual environments in memory rehabilitation.[3] Despite the assumption that immersive virtual reality can increase patients' motivation towards monotonous recurring tasks as it was formerly connected to amplified amusement, there is no data to endorse this and upcoming studies are required to address this subject.[3] Regarding the very inadequate number of studies that directly compare non-immersive and immersive virtual environment in memory training, it is not likely to conclude if immersive virtual reality training is superior.


  1. Lombard M, Ditton T. At the heart of it all: The concept of presence. J Comput Mediat Commun 1997;3:JCMC321.
  2. Laamarti F, Eid M, El Saddik A. An overview of serious games. Int J Comput Games Technol 2014;2014.
  3. Plechatá A, Nekovářová T, Fajnerová I. What is the future for immersive virtual reality in memory rehabilitation? A systematic review. NeuroRehabilitation 2021;48:389-412.
  4. Harada CN, Natelson Love MC, Triebel KL. Normal cognitive aging. Clin Geriatr Med 2013;29:737-52.
  5. Medalia A, Choi J. Cognitive remediation in schizophrenia. Neuropsychol Rev 2009;19:353-64.
  6. Rohling ML, Faust ME, Beverly B, Demakis G. Effectiveness of cognitive rehabilitation following acquired brain injury: A meta-analytic re-examination of Cicerone et al.'s (2000, 2005) systematic reviews. Neuropsychology 2009;23:20-39.
  7. Grynszpan O, Perbal S, Pelissolo A, Fossati P, Jouvent R, Dubal S, et al. Efficacy and specificity of computer-assisted cognitive remediation in schizophrenia: A meta-analytical study. Psychol Med 2011;41:163-73.
  8. Hill NT, Mowszowski L, Naismith SL, Chadwick VL, Valenzuela M, Lampit A. Computerized cognitive training in older adults with mild cognitive impairment or dementia: A systematic review and meta-analysis. Am J Psychiatry 2017;174:329-40.
  9. Motter JN, Pimontel MA, Rindskopf D, Devanand DP, Doraiswamy PM, Sneed JR. Computerized cognitive training and functional recovery in major depressive disorder: A meta-analysis. J Affect Disord 2016;189:184-91.
  10. La Corte V, Sperduti M, Abichou K, Piolino P. Episodic memory assessment and remediation in normal and pathological aging using virtual reality: A mini review. Front Psychol 2019;10:173.
  11. Slater M, Sanchez-Vives MV. Enhancing our lives with immersive virtual reality. Front Robot AI 2016;3:74.
  12. Cummings JJ, Bailenson JN. How immersive is enough? A meta-analysis of the effect of immersive technology on user presence. Media Psychol 2016;19:272-309.
  13. Greenwood KE, Morris R, Smith V, Jones AM, Pearman D, Wykes T. Virtual shopping: A viable alternative to direct assessment of real life function? Schizophr Res 2016;172:206-10.
  14. Maggio MG, De Luca R, Molonia F, Porcari B, Destro M, Casella C, et al. Cognitive rehabilitation in patients with traumatic brain injury: A narrative review on the emerging use of virtual reality. J Clin Neurosci 2019;61:1-4.
  15. Dehn LB, Kater L, Piefke M, Botsch M, Driessen M, Beblo T. Training in a comprehensive everyday-like virtual reality environment compared to computerized cognitive training for patients with depression. Comput Human Behav 2018;79:40-52.
  16. Gamito P, Oliveira J, Santos N, Pacheco J, Morais D, Saraiva T, et al. Virtual exercises to promote cognitive recovery in stroke patients: The comparison between head mounted displays versus screen exposure methods. Int J Disabil Hum Dev 2014;13:337-42.

  Experience of COVID 19 and Neurorehabilitation Symposium Top

  Rehabilitation in COVID19 Sri Lankan experience Top

Gamini Karapitiya Pathirana

Neurologist, Sri Lanka

Neuro rehabilitation in COVID 19 – Sri Lankan experience Sri Lanka is an island nation situated within Indian ocean. It has 48 neurologists serving a population of 20.2 million at present. Stroke is the sixth leading cause of death and fifth leading cause of disability in the country. It has a stroke prevalence of close to 10 per 1000. Sri Lanka runs 10 stroke units throughout the country. State sector provides 95% of stroke care within hospitals. Most stroke patients still do not receive rehabilitation due to inadequate availability of such services in the state sector. Contribution for stroke rehabilitation in the private sector is negligible where only a small percentage of stroke patients are being rehabilitated. Physiotherapy, occupational therapy, speech therapy and social services were available in most hospitals. Dedicated rehabilitation teams serving stroke patients are seen only in 3 teaching level hospitals. Such teams are usually headed by neurologists. Sri Lanka has no stroke physicians with formal stroke training or accreditation for stroke care Majority of stroke patients are managed by general physicians in internal medicine. Post graduate institute of Sri Lanka (PGIM) is in the process of producing specialists in medical rehabilitation who may contribute for rehabilitation needs in the country very soon. Sri Lanka does not have separate neuro rehabilitation hospitals as such. At present neurologists look after neuro rehabilitation needs within their ward setting with the support from available therapists within such hospitals. Stroke rehabilitation too is done to a limited capacity within stroke units which again are run by neurologists. Rehabilitation in Sri Lanka was taking place both as inpatient and as outpatient. We do not have community rehabilitation programmes or teams. Inpatient rehabilitation takes place by the rehabilitation teams usually headed by the neurologists and we conduct weekly team meetings to discuss progress and to plan activities. Outpatient rehabilitation takes place as patients visit rehab facilities. Such home-based rehabilitation was supported by family members being trained to carry out the exercise programmes. State sector does not provide 'therapist visiting home service'. This service is available through the private sector where certain patients are being visited mostly by physiotherapists. As far as COVID 19 infection is concerned. We had our first COVID case reported in a Chinese tourist from Hubei on 27th January 2020. Since then, we experienced 3 waves of the pandemic comparable with most other countries. We were able to manage the first and second waves efficiently. Now with the third wave Sri Lanka is in a partial lock down continuing for the second month at the time of writing. Health staff are given approval to travel to the workplace to run hospital services with minimum capacity. We experience that there is reluctance in stroke patients arriving at hospitals both for acute treatment as well as rehabilitation. Patients and families prefer to do rehabilitation from home where the rehab team sees them in the outpatient department. Despite such reluctance most needy patients are still being rehabilitated within stroke units. Rehabilitation was a challenge during the lockdown period. Patients were tested for COVID 19 when admitted to the stroke rehabilitation unit. Therapists were carrying out their therapy sessions in Personal protective Equipment (PPE). visitors were not allowed into the stroke unit. A family member who could help patient therapy activities was allowed to stay with the patient after being tested and negative for COVID 19. Interviewing and examining rehab patients by doctors and therapists was done in the ward. Our doctors, therapists were in full PPE while interviewing and carrying out close examination, therapy sessions. Team discussions were done in a room while maintaining social distance. Some patients were reluctant to accept in center rehabilitation when offered. More patients were diverted to either outpatient rehab or home-based rehabilitation whenever possible especially where there was a particularly good family participation. Others who need inpatient rehabilitation were offered such services in the same way it had been in the past, while taking precautions to prevent the spread of the disease. Those who had COVID 19 infection complicated with stroke were looked after in a separate isolation ward together with other COVID positive patients. Such patients too were offered rehabilitation while being treated for COVID19. For a significant number of rehab patients, close family members were extremely useful regarding carrying out rehab sessions during COVID 19 era. Dr Gamini Pathirana Neurologist with interest in stroke care National Hospital of Sri Lanka President – Association of Sri Lankan Neurologists.

  Hyperbaric oxygen and carbon dioxide, therapies, as – including physiatric/rehabilitation – interventions in spinal cord injury: Systematic and synthetic literature review Top

Gelu Onose1, 2, 3, 4, 5, Constantin Munteanu2, 3, 5, 6, 7

1Department of Physical and Rehabilitation Medicine, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 2Neuromuscular Rehabilitation Clinic Division, The Teaching Emergency Hospital Bagdasar-Arseni, 3Romanian Spinal Cord Society, 4Romanian Society for NeuroRehabilitation, 5Romanian Society of Physical and Rehabilitation Medicine and Balneoclimatology, 7Romanian Association of Balneology, Bucharest, 6Faculty of Medical Bioengineering, The University of Medicine and Pharmacy - Grigore T. Popa, Iaşi, Romania

Background and Aims: Spinal cord injury (SCI) is a severe neurological sufferance, yet without efficacious treatment, by now. SCI often results in tetra- or para-plegia, associated with vegetative disturbances – affecting also micturition and/or defecation and or sexual/reproductive, functions – thus often severely jeopardizing the quality of life (QOL) in such patients. At tissue level, SCI usually causes neuronal death and axonal damage, ischemia, oxidative stress, neuroinflammation (involving the activation of microglia and astrocytes by related mediators), glial fibrous scar, and possibly cyst/syringomyelia formation, interruption of nerve communication mechanisms, all within a consequent local microenvironment hostile to neuroregeneration/re-connection. Recently, some advances have been made towards understanding the role of autophagy, too – a very efficient and subtle intimate biologic mechanism, acting in both: physiological and pathological conditions and also, pending on complex circumstances, being pro-apoptotic but as well conversely: favoring cells survival, by being involved including in cytoplasmic organelles' refurbishment and thus, by sorting the rescuable ones, saving energy and biological material – in the central nervous system (CNS) injuries, including in SCI; promoting removal of such damaged subcellular/cellular moieties, autophagy may contribute to endogenous resilience and recovery.

At least in the last half-decade, some studies found that Hyperbaric Oxygen Therapy (HBOT) significantly protected of embitterment, after SCI, also through stimulating autophagy, in animal experimental models, supporting cell repair. It has served as a non-invasive medical intervention for more than 100 years. In the literature it is shown that HBOT can significantly improve spinal cord tissue oxygen tension and oxygen diffusing capacity, reduce oedema and haemorrhage, support the recovery of nerve tract functions, and as well, reverse various path-physiological processes and/or promote reparative ones, after SCI. More recent papers confirmed that the application of HBOT (combined for instance with drugs and surgery), after SCI, can reduce neurological deficits – including with the improvement of motor functions and thereby, the functioning of the affected patients' QOL. So, although its potential effects and underlining mechanisms remain, at least partially, unknown, HBOT seems to be a possible therapy for SCI, and hence worth to be further approached, in this respect, too.

Carbon dioxide (CO2) is more recently reported to have some beneficial actions in acute SCI experimental animal models, including similar effects with those of physical exercise in post-SCI conditions. Specifically, administered transcutaneous, it would operate at nuclear, cellular, muscle tissue and articular, levels (mitigating the gene expression of the Type I collagen mRNA and respectively, of the TGF-β1 – both connected with fibrosis (including – precocious – in joint capsules) development –, stimulating mitochondrial energetics – prone to preserving muscle functionality (”fiber type switching” and endurance enhancement), and also trophycity, based on angiogenesis and vasodilatation with more oxygen input, and consequent improved blood supply to the muscles, too, in the territories exposed to CO2 therapy. Thus, this type of pyshiatric intervention might be an alternative treatment of contractures – a major complication in patients with SCI, preceding and associating to spasticity – thereby resulting in related segmental range of motion enhancement, as well.

Methods: We have documented this work based on an inspired by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. Thereby, we quested for open access articles, published in English during the last five years, through interrogating the following international medical databases: Cochrane, Elsevier, National Center for Biotechnology Information (NCBI)/PubMed, NCBI/PubMed Central (PMC), Physiotherapy Evidence Database (PEDro), and Institute for Scientific Information (ISI) Web of Knowledge/Science (the latter was used to identify articles published in ISI indexed journals, as only such ones have been considered eligible). For this purpose, we have contextually searched by keywords combinations/syntaxes (”Spinal Cord Injury/SCI AND Hyperbaric oxygen therapy/HBOT”; “Spinal Cord Injury/SCI AND Carbon dioxide/CO2”), in the title and abstract of the articles.

Results: Our search identified, initially 123 articles. After fulfilling the steps of the PRISMA-inspired selection methodology, including with the application of the PEDro inspired indirect qualitative filtering classification scoring, there remained 15 papers that have been carefully full-text analysed.

Conclusions: HBOT has been shown in experimental studies, to exert neuroprotective actions in SCI, mainly: improving spinal cord oxygen tension, decreasing apoptosis, reducing inflammation, attenuating oxidative stress – the “hallmark” of the intimate damages mechanisms of the “secondary lesions”, including in SCI – and promoting angiogenesis and autophagy. However, only a few clinical reports have been performed, in this respect, and they have shown conflicting outcomes, thereby warranting further studies to elucidate the optimal HBOT paradigm and to determine if the respective schemata should depend on the specific type of SCI. CO2 may improve muscular fibrosis because of the reduced gene expression of Type I collagen, thereby boosting the muscular injury repair – including through the mitochondrial energetics link – in post SCI statuses.

  Aqua Therapy Top

  Aquatic Therapy as “a Game Changer” – Experience and Learning Top

Gerda Joubert

Private Practitioner


Introduction: Aquatic Therapy is an essential part to the idea of life through movement. The support of the water creates “a dare to fall” environment that offers patients a wider range of possibilities to correct their movement for themselves. The case study used for the “Aquatic Therapy as a Game Changer – Experience and Learning” workshop was documented in 2013-2014. This was before COVID-19. The current pandemic has created extra challenges that should be taken in consideration within the aquatic environment and to be addressed in future aquatic therapy case studies. The Case study's ICD-10 codes include: B91 Sequelae poliomyelitis G81.04 Flaccid hemiplegia affecting the left nondominant side I69.351 Hemiplegia and hemiparesis following cerebral infarct of right dominant side This workshop focuses on Aquatic therapy as “a game changer” in the physical therapy regime received by a 73- year-old female patient. The patient had contracted Poliomyelitis in her childhood years, which affected her left non-dominant side. Although both her left upper and lower extremities were affected, she was still able to walk independently, with an adapted walking pattern, and take care of everyday necessities without assistance. However, at the age of 73 she suffered a stroke which affected her right dominant upper and lower extremities. The stroke caused her to be wheelchair bound. It is important to note that at the time aquatic therapy intervention took place her medical condition was stable. The patient was referred for physical therapy 8 months after she had suffered the stoke. Furthermore, for the first 5 months following the stroke she was completely wheelchair bound. The last 3 months before aquatic therapy commenced, she was able to stand up from her wheelchair and move from and to a chair or bed. However, this was all done with assistance. As a result of her increased sedentary lifestyle her body weight increased significantly. The patient's referring physician as well as her family mentioned noticing signs of depression. The patient however denied having depression. The family was part of a small but close-knit farming community and since the stroke her socialization became limited. During consultation with the patient, she reported a fear of falling that prevented her from attempting to walk aided and unaided. The patient's fear of falling is one of the factors that prompted the decision to suggest the use of aquatic therapy as treatment modality. At this point it should be noted that the patient had no previous experience in a pool and had a fear of drowning because of her limited movement abilities. The introduction of aquatic therapy as part of the patient's treatment regime needed to be accepted and approved of by both the patient and her supporting family. A patient's acceptance and approval of any treatment is paramount. The patient's main aim for participating in the treatment was prompted by her need to become independent from her caretaker and family members for every-day living activities and to walk independently.[2] The diagram below represents the patient's International Classification of Functioning, Disability and Health (ICF) (Adapted from: World Health Organization. 2001. ICF). Health Condition Poliomyelitis & Stroke Body Function and Structure Functions: muscle strength and tone, joint motion, voluntary movement pattern, sensation Structures: unilaterally arms and legs, trunk Cognition cardiovascular fitness spasticity sensation Activities Mobility: walking and moving around, walking speed and endurance Execution of a task: reaching and grasping ADL Participation Return to normal domestic life Independent eating and dressing Community integration and recreation Environmental Factors Wheelchair/walker/cane Accessibility and safety Living situation, support structure, available services Personal Factors Age, marital status, selfmotivation and self-efficacy, readiness to change, coping mechanism, socioeconomic status Falls.[3] The Treatment Plan: The treatment plan designed for the patient mentioned in the case study had to consider the effect that the fundamental principles of water (Hydrostatics, Hydrodynamics, Thermodynamic) would have on her already compromised body structure and functions. The patient also had to be mentally prepared for the effect that the water would have on her body. The treatment of a patient follows a pattern where, a successful cognitive phase will lead the way to the associative phase, followed by a successful autonomic phase. Postural control precedes movement control and the patient had to be re-educated in postural control. A multi-disciplinary team approach is essential for the holistic success of a patient's therapy process. Therefore, communication with the other professionals involved had to be maintained and feedback incorporated where possible into the treatment schedule of the day. The patient's treatment plan included the use of land-based activities more familiar to the patient and then progression into introducing more advanced aquatic therapy techniques. Attention was given to activities focusing on fall prevention and crossing of midline activities. During water therapy a safe and successful entry to and exit from the pool was crucial. These two phases can be seen as a “make or break” situation. The trust of the patient in the therapist and the aquatic environment can be heavily impacted during these two phases of therapy.

Findings: While using aquatic therapy, the patient's mental adaptation took longer than expected. The cause of this was because she was completely unfamiliar with the effects of the water properties. This influenced the introductory phase to the pool and therefore it took longer than expected to progress and reach the aim of her walking independently in the pool. The same situation was found with the implementation of the disengagement phase of the therapist from the patient in the pool. Later, during therapy the effort to introduce more advance aquatic therapy techniques was unsuccessful and in fact had a more negative impact on her balance and general body awareness. Especially when going into supine positions. The readiness of the patient needs to be carefully considered when introducing the next or new phase in a treatment plan. Progression in a treatment plan however cannot be delayed but only slowed; this is important for preventing stagnation in a patient's progress. While treating this patient it was also noticed that despite having a supportive and caring family, their presence in the pool area was found to have had both a positive and negative effect on the patient's performance of the day. The emotional pressure for improvement was felt by both parties. As therapy progressed and mutual trust established, the patient's mischievous and fun personality surfaced making it easier towards the end of the therapy period to introduce some fun and games during therapy sessions.

Conclusion: In conclusion, thinking outside the box of the conventional aquatic therapy process is important. Optimize that which the patient is willingly offering you to work with. The element of fun in the water adds value to a session. Movement restricted patients should be guided to find their own balance and movement patterns. Aquatic therapy was “a game changer” in this patient's life as it assisted her in finding her new balance point, creating her own new adaptive waking pattern, and become independent to the maximum degree from her caretaker and family's assistance.[4]


  1. Campion MR. Hydrotherapy-Principles and Practice. Oxford: Butterworth Heinemann; 1997.
  2. Carse D. Aqua-Rhythmics – Everybody's Guide to Safe and Efficient Water Exercising. Johannesburg: Human and Rousseau; 1991.
  3. Kourney JM. Aquatic Therapy Programming-Guidelines for Orthopedic Rehabilitation. USA: Human Kinetics; 1996.
  4. Lambeck JF, Gamper PT. The halliwick concept. In: Becker BE, Cole AJ, editors. Comprehensive Aquatic Therapy. USA: Washington State University Publishing; 2011. p. 77-107.
  5. Morris DM. Aquatic rehabilitation for the treatment of neurological disorders. J Back Musculoskelet Rehabil 1994;4:297-308.
  6. Leonardi M, Fheodorof K. Goal setting with ICF (international classification of functioning, disability and health) and multidisciplinary team approach in stroke rehabilitation. In: Thomas P, editor. Clinical Pathways in Stroke Rehabilitation – Evidence-Based Clinical Practice Recommendations. Switzerland AG: Springer Nature; 2021. p. 35-56.
  7. Ruoti RG, Morris DM, Cole AJ. Aquatic Rehabilitation. NY: Lippincott; 1997.

  Spinal cord injury management – Strengths, weaknesses and challenges in the Indian scenario Top

H. S. Chabbra

India had been very slow in responding to the revolutionisation of spinal injury management which took place almost seven decades ago. The needs of the Indian Society have been different because of relative paucity of resources, differences in epidemiology and substantial rural concentration of population. It has been only in the last three decades that attention has been focused on setting up services for SCI management. A few centers of excellence emerged. However, the services available are largely inadequate to meet the needs of the second largest population of the world. In addition, there are numerous challenges like inadequate awareness, late presentation to definitive institution, financial barriers and paucity of trained manpower, which prevent spinal cord injured in India to get the benefits of optimum management as per the established standards.

Despite its established importance in improving outcome, pre-hospital care is grossly deficient and one of the most neglected components of spinal cord injury management resulting in significantly higher morbidity and mortality. Lack of formal prehospital care systems and adequate equipment as well as long transport times to the nearest health facility pose a big challenge.

Spinal cord injured patients often present quite late to the definite center in less developed countries. They have had either inadequate or no treatment and there is often an unsupervised period at home. Delay in initiation of comprehensive management of SCI leads to higher incidence of complications and compromised outcomes.

Acute in-hospital management is not as neglected as the other aspects of SCI management. However, a significant percentage of patients are sent back home after acute management.

Anticoagulant prophylaxis is often not administered in the Asian setting due to the belief that the incidence of DVT is much lower than in the West.

The multidisciplinary comprehensive care required for SCI management is often provided by a few disciplines namely physicians, physiotherapists and nurses. Hence, they are required to multitask for care normally provided by other members of the team.

Aspects of care like sexuality and fertility counseling, occupational therapy, assistive technology, educational classes, vocational counseling, pre-discharge home visits and follow up home care services are especially deficient. Community inclusion and lifelong follow up also pose a significant challenge. Prevention programs are quite inadequate and need a major boost.

Knowledge about evaluation procedures for bladder management and access to them is limited. Many patients are not initiated on CIC and continue to be on indwelling catheter, condom catheter, reflex voiding or even voiding through Crede's maneuver. Paucity of disposable catheters further adds to the challenges in management of the neurogenic bladder. Guidelines are available for use, processing, and storage of reusable catheters, but knowledge in this regard is not adequately disseminated.

The delay in initiation of bowel training predisposes patients to fecaliths, impacted bowel, and associated complications like hemorrhoids as well as pressure sores and autonomic dysreflexia.

Sexual counseling and management is one of the most neglected aspects of SCI in the less developed countries. The prominent cause for this is lack of awareness and cultural taboos. Fertility counseling and management is also not given adequate importance.

Complications are similar to those seen in developed countries but there is a higher incidence, probably due to inadequate and inappropriate management as well as delay in its initiation. The rate of genito-urinary and renal complications in people with spinal cord injury in less developed countries continues to be quite high. Pressure ulcers and preventable secondary infections pose another major challenge in the management of spinal cord injuries. There is increased incidence of spasticity and secondary contractures.

Home care services are almost negligible and nonexistent in less developed countries. Follow-up poses a big challenge and the follow-up rates are low.

A significant percentage of SCI do not get appropriate assistive devices. Accessibility, both within the community and at home, poses a major challenge for persons with spinal cord injury in less developed countries. Architectural barriers like improper roads, infrastructure, and nonwheelchair friendly houses as well as the rough terrains are all barriers to community inclusion.

There are very low rates of return to vocation in less developed countries. There is insufficient data on prevalence and incidence of SCI in the less developed nations which poses a challenge for formulation of effective prevention programs. Implementation and enforcement of prevention programs is also inadequate.

However, there are a number of strengths in the India system which help the spinal injured to overcome the challenges. The strong family and community support has perhaps the most important positive influence on outcome. Strong religious beliefs and especially facets like “Doctrine of Karma” help them cope with the disability and face the challenge successfully.

The challenges also perhaps stimulate the health professionals to come out with innovative ideas to help the spinal cord injured to get back to the mainstream of the society. Reusable catheters, clean cotton cloth bag for storing catheters, floor mobility device, training attendants for care giving even in acute phase and honey/vinegar for pressure sore dressings are some of the examples of the innovative mind. The relatively cheap and abundant availability of manpower further helps the spinal injured, especially tetraplegics, to freely avail the services of a caregiver.

All stakeholders including the Government, Healthcare providers, professional orgnaisations like AOCNR, Consumers and the Society need to fulfill their roles and responsibilities inorder to overcome the challenge posed by Spinal Cord Injury.

Thus, even though the spinal injured face a lot of challenges in the Indian scenario, the strengths of the system are helping a progressively increasing number to get back into the mainstream of the Society.

  Experience of COVID 19 and Neurorehabilitation Symposium Top

  View Point from Taiwan Top

Hung-Chou Chen

Assistant Professor, School of Medicine, College of Medicine Taipei Medical University, Taiwan

Neurological Involvement after COVID-19: -7.8% to 36.4% of Covid-19 patients suffered from varies kinds of neurological symptoms, with a higher rate in patients with severe infection. -1.4% to 3.0% patients suffered from acute cerebrovascular diseases, with a higher rate in Asia patients. -Up to 9.8% of post-critical care Covid-19 patients suffered from Critical illness-associated weakness. -Early evaluation and treatment of these neurological symptoms are important.

  Introduction to the Autonomic Nervous System Top

Indu Nanayakkara

Department of Physiology, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka


Autonomic nervous system is responsible for maintaining homeostasis of the internal environment. It is anatomically not well defined and its distribution is diffused. However, the autonomic nervous system (ANS) controls some of the very important functions of the body including heart rate and blood pressure, respiration, digestion, storing and voiding of urine and sexual functions. Conventionally, the ANS is divided into two sub divisions the sympathetic nervous system and the parasympathetic nervous system. However, more recently there is a third division identifies separately, which is the enteric nervous system. The enteric nervous system is involuntary in its activity, acts independently but is influenced by the sympathetics and parasympathetics.

The remarkable feature of the ANS is the rapidity and the intensity with which it acts. The ANS basically innervates the heart muscle, smooth muscles of blood vessels, gut and the genitourinary systems, glands – mostly exocrine but some endocrine glands and adipose tissue.

It is well known that the autonomic motor pathways consist of two neurons separated by a ganglion which is actually a conglomerate of nerve cell bodies acting as a relay station. The ganglion in the case of the sympathetic nervous system is situated close to the central nervous system whereas, in the case of the parasympathetic nervous system it is situated very close to the target organ, hence the name 'parasympathetic' to indicate 'next to' or 'close to' the target organ.

Most organs have dual innervation by the two subdivisions of the autonomic nervous system. The neurotransmitters secreted by the nerve endings and the receptors present at the target tissue are diverse producing a wide variety of effects in the body. Irrespective of whether it is the sympathetic division or the parasympathetic division, the preganglionic nerve cells secrete acetylcholine and the receptor in the postganglionic cell body is a nicotinic type cholinergic receptor. They belong to type 2 nicotinic receptors which are different to what is found in the skeletal muscles at the neuromuscular junction (which belongs to type 1 nicotinic receptors). In the case of the target organs in relation to the parasympathetic nervous system the post ganglionic cells are cholinergic and the target organs carry muscarinic acetylcholine receptors. In fact, the target cells express M1-(salivary glands, stomach), M2- (cardiac nodal cells), or M3-type (smooth muscle, many glands) muscarinic receptors. Most sympathetic postganglionic neurons release norepinephrine from their terminals and hence the target organs carry alpha or beta receptors. The exceptions being the sympathetic efferents that innervate eccrine sweat glands, which release acetylcholine at their terminals and act through an M3-type acetylcholine receptors.

The only nerves that do not have a ganglion before reaching the target organ are the sympathetic nerves travelling to the adrenal medulla, where the preganglionic nerves end on the adrenal medullary secretory cells and the adrenal medullary cells act as the post ganglionic nerve secreting epinephrine and a small amount of norepinephrine.

Although it is said that there is dual innervation of organs, there are a few exceptions. One of them is the systemic blood vessels. They are innervated entirely by sympathetics adrenergic nerves and the receptors are alpha one adrenergic. Sweat glands are also lacking in parasympathetic innervation with eccrine glands being innervated by sympathetic cholinergic while the apocrine sweat glands being innervated by adrenergics acting on alpha-1 adrenergic receptor. When it comes to receptor subtypes although several subtypes will be present in any given tissue, one subtype will predominate and that would be taken as the receptor type present in the given organ. Receptors at the post synaptic membrane are generally either G-protein coupled receptors or ligand-gated channels. Therefore, activation of these receptors would either activate or inactivate intracellular enzymes or increase the permeability to some ion.

If one were to look at the general organization of the sympathetic nervous system, the preganglionic fibers come out from 1st thoracic to the 2nd lumbar segments of the spinal cord. Once they exit the spinal cord they may take one of several pathways. The small white myelinated fibers enter the paravertebral sympathetic chain of ganglia where they may synapse with the post ganglionic neuron in the ganglion they enter or one or two ganglia above or below. Alternatively, they may go through the chain and synapse in one of the prevertebral ganglia (coeliac, aorticorenal, superior mesenteric or inferior mesenteric). Some fibers travelling to the adrenal medulla may not synapse until they reach the adrenal medullary cells. The unmyelinated grey fibers that exit the sympathetic chain join with somatic spinal nerves to reach its target organs.

In the case of the parasympathetic nervous system, 90% of the fibers are carried in the two vagus nerves. In addition to the vagus nerve, the other cranial nerves involved with parasympathetic fibers are the cranial nerves III, V, VII, IX. The cranial part of the parasympathetic fibres supply the entire body's parasympathetic innervation except for the supply to the pelvic organs. The pelvis organs such as the urinary bladder, lower parts of the ureter, urethra, reproductive organs, the gut from below the splenic flexure is supplied by the parasympathetic components from the sacral segments S1-S3.

As mentioned previously, the current trend is to consider the enteric nervous system in the myenteric and meissner plexus as a separate entity from the sympathetics and parasympathetics. They control the digestive functions of muscle contraction/relaxation, secretion/absorption, and blood flow in the gastrointestinal tract through a multitude of reflexes. The enteric nerve functions are highly influenced by the sympathetics and the parasympathetics.

Autonomic nervous system is a complex and dynamic nervous system that helps in keeping the stability of the internal environment and through the hypothalamus it helps in integrating nervous signals with endocrine activity in the body.

  Symposium on Telerehabilitation Top

  Developing telerehabilitation in rural area Top

Irma Ruslina Deli

Physiatrist, Indonesia


What are Telemedicine and Virtual Care

The term telemedicine refers specifically to the treatment of various medical conditions without seeing the patient in person. Healthcare providers may use telehealth platforms like live video, audio, or instant messaging to address a patient's concerns and diagnose their condition remotely, functioning as a stand-alone service parallel to-face consultations. And virtual care is a broad term that encompasses all the ways healthcare providers remotely interact with their patients. In addition to treating patients via telemedicine, providers may use live video, audio, and instant messaging to communicate with their patients remotely.[1]

Both telemedicine and virtual care have the same functions: connecting providers and patients to provide health care services when they are not in the same location; information delivery method: synchronous or asynchronous; using information and communication technology to exchange valid information for the diagnosis, treatment, and prevention of disease and injury in the interest of advancing individual health.

Definition and Scope

Telemedicine is the provision of remote health services by health professionals using information and communication technology, including the exchange of information on diagnosis, treatment, prevention of disease and injury, research and evaluation, and continuing education of health service providers for the benefit of improving individual and community health.[2]

Telerehabilitation is the application of telecommunication technology to provide distance support, assessment, and intervention to individuals with disabilities.[3]

Telemedicine Guideline in South East Asian (SEA) Countries

By knowing development of telemedicine in SEA countries, we can related with developing tele-rehabilitation in rural area. In general, most SEA countries have telemedicine guidelines of varying breadth and depth. The majority of the SEA guidelines concentrated on telemedicine's ethical and clinical aspects, with less emphasis on the technology or platform used to provide the service [Table 1].[4]
Table 1: The domain contained in the telemedicine guideline of South East Asian countries[4]

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Implementation Challenges of Tele-Rehabilitation Services

Eight aspects affect the implementation challenges of telerehabilitation services in a rural area, including policy, organization, accreditation, service, infrastructure, team, legal, financial, and social [Figure 1]. In policy aspect including guidelines, there is a big gap between policy and regulation for telerehabilitation implementation. In the organization aspect, no government or academic organization takes care of this service to take advantage of this service. And no specific foundation or organization can assess whether telerehabilitation is done properly and correctly. This is needed to make telerehabilitation is equal to other telehealth services or ordinary health services. Technology aspect, divided into two major aspects, which are services and infrastructure. To improve the telerehabilitation service, a solid development team is required. This includes the doctor itself, application developer, and project owner who understands IT and data transactions. The legal aspect is needed if legal disputes arise or malpractice, electronic prescription dispute, telerehabilitation provider license. In the financial aspect, developing a telerehabilitation service needs high cost, but on the other hand, the results of these services cannot be gained quickly and are questionable. In the social aspect, we are facing the rural population who has poor IT literation. They still feel not comfortable with technology, for example, they prefer to see the doctor offline, so they feel being treated.[5]
Figure 1: Cycle aspects of telemedicine barrier

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Tele-Rehabilitation Service Development Approach

Tele-rehabilitation service development approach can be implemented to set up telerehabilitation services. There are two objectives in tele-rehabilitation service development, cost reduction or revenue generation. If we choose cost reduction, we can develop the waterfall model using a sequencing process [Figure 2]. And if we focus on revenue generation, we can use the agile model and lean validation to develop the application [Figure 3]. The combination between the waterfall model and agile model is possible because, in the agile model, a task has a short timeline and very clear scope, so a small project with a waterfall model can be implemented [Figure 4].
Figure 2: Waterfall model[6]

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Figure 3: Agile model and lean validation[7]

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Figure 4: Combination agile model and waterfall model[6]

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The Approach of Tele-Rehabilitation Technology

A technology review was done to ensure the availability of infrastructure capable of delivering a service. To develop telerehabilitation services, we must understand what technology can be used to develop those services. What is needed is not only exchanging data information through mobile applications but there are other technologies required, for example, specifically serving users in rural areas where mobile connectivity does not exist. It is divided into three layers, (1) ecosystem service layer, (2) platform layer, (3) connectivity layer [Figure 5]. There is a lot of choice in the connectivity layer, but we focus on the most relevant telerehabilitation: fiber optic, mobile, and satellite. These choices depend on the objective of the digital product. There is a lot of alternative technology in the platform layer, for example, IoT, data center, cloud, big data, security, and artificial intelligence. This choice and roadmap are depended on the target to develop the product.
Figure 5: Tele-rehabilitation technology review

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Telemedicine Implementation

The example of telemedicine implementation using the waterfall method developed 20 years ago. At that time, no internet network was as easy to manage as it is today, so to transmit data in the form of images and sound, voice, telecommunication, and radio networks were used [Figure 6].[8] Ten years ago, a waterfall method was used to measure how a transaction transfers data from a disaster location using a Low Altitude Platform for Emergency Medical Comm and also digitalization of maternal and post-natal care system.[9] The technology used at that time was WiFi and WMAX [Figure 7]. An example of an agile and lean implementation is related to the COVID-19 tracing, tracking, and vaccine application [Figure 8]. The development process is preceded by finalizing the user candidate's experience research journey, then the connectivity and infrastructure of the platform are carried out. Everything starts from the smallest thing and will grow every day to be evaluated and immediately redeveloped when needed. Hence, there is no need to finish everything first, like in the waterfall method. If some things are not clearly related to the user's needs, we will first validate whether this is really what the user needs.
Figure 6: Developing telemedicine implementation using waterfall model in 2002 – 2005

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Figure 7: Developing telemedicine implementation using waterfall model in 2009 – 2014

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Figure 8: Telemedicine implementation using the agile model

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The challenges of infrastructure for Tele-rehabilitation services are (1) Very fast technology development; (2) Inequality in ICT infrastructure; (3) Expensive investment; and (4) Slow internet access. The challenges of service technologies are (1) Slow service maturity (2) Unclear orientation of market and industry needs. Even with regularly updating technology developments, the availability of infrastructure needed for Tele-rehabilitation services has not reached all remote areas. The technical architecture for telerehabilitation can use a combination of connectivity and platform technologies based on service configuration specifications.


  1. Jones M, Craft L. Hype cycle for digital care delivery including telemedicine and virtual care. In: Gartner Research. 2018. Available from: https://www.gartner.com/en/documents/3882881/hype-cycle-for-digital-care-delivery- including- telemedic.
  2. Moeloek NF, Ekatjahjana W. Permenkes No. 20 Tahun 2019 Tentang Penyelenggaraan Telemedicine Antar Fasilitas Pelayanan Kesehatan. Ministry of Health; 2019. Available from: https://www.researchgate.net/publication/338428993.
  3. Ricker JH, Rosenthal M, Garay E, DeLuca J, Germain A, Abraham-Fuchs K, et al. Telerehabilitation needs: A survey of persons with acquired brain injury. J Head Trauma Rehabil 2002;17:242-50.
  4. Intan Sabrina M, Defi IR. Telemedicine guidelines in South East Asia – A scoping review. Front Neurol 2020;11:581649.
  5. Bali S. Barriers to development of telemedicine in developing countries. In: Telehealth. 2018. [doi: 10.5772/intechopen. 81723].
  6. Kukhnavets P. Agile vs Waterfall Defining the Difference Between Two Powerful Methodologies. Available from: https://hygger.io/guides/agile/agile-vs-waterfall/.
  7. Okeke N. Agile Methodology: Meaning, Advantages, Disadvantages & More. Available from: https://targettrend.com/agile-methodology- meaning-advantages-disadvantages-more/.
  8. Sutiono AB, Qiantori A, Prasetio S, Santoso H, Suwa H, Ohta T, et al. Designing an emergency medical information system for the early stages of disasters in developing countries: The human interface advantage, simplicity and efficiency. J Med Syst 2010;34:667-75.
  9. Qiantori A, Sutiono AB, Hariyanto H, Suwa H, Ohta T. An emergency medical communications system by low altitude platform at the early stages of a natural disaster in Indonesia. J Med Syst 2012;36:41-52.

  Urological and sexual autonomic dysfunction in neurological disorders Top

Jalesh N. Panicker

Department of Uro-Neurology, Reader in Uro-Neurology and Clinical Neurology, The National Hospital for Neurology and Neurosurgery and UCL, Institute of Neurology, Queen Square, London, United Kingdom

Lower urinary tract (LUT) and sexual dysfunction are commonly reported sequelae of neurological disease and have a significant impact on quality of life. Neurologists are increasingly enquiring are increasingly becoming involved in the management of these complaints.

The pattern of LUT dysfunction is influenced by the site of neurological lesion. The risk for developing upper urinary tract damage is considerably lower in patients with slowly progressive non-traumatic neurological disorders, compared to patients with spinal cord injury or spina bifida. History taking forms the cornerstone of assessment, and urinalysis, ultrasonography and urodynamics provide information about the cause and nature of LUT dysfunction. Antimuscarinic agents are the first line management of urinary incontinence, however the side effect profile and anticholinergic burden should be considered when prescribing these medications. Beta-3 receptor agonists are a promising alternative oral medication. Tibial and sacral neuromodulation have been shown to be effective for managing neurogenic incontinence. Intradetrusor injections of onabotulinumtoxinA have revolutionised the management of neurogenic detrusor overactivity. Phosphodiesterase-5 inhibitors are the first line management for managing neurogenic sexual dysfunction. Neurological patients reporting LUT symptoms require a comprehensive evaluation for planning a patient-tailored approach to management.

[TAG:2]Research Methdology in [/TAG:2]

  Neurorehab Top

  Pragmatic and implementation trials for low and middle-income countries Top

Jeyaraj D. Pandian

Principal and Professor of Neurology, Christian Medical College and Hospital, Ludhiana, India

There are several challenges in delivering stroke rehabilitation in LMICs. Even though there are many evidence based stroke rehabilitation strategies available whether they are effective in LMICs is unclear. Hence there is a need for pragmatic stroke implementation trials. The Family led stroke rehabilitation trial (ATTEND) was one such pragmatic stroke rehabilitation trial done in India. The caregivers were trained by the physiotherapists and the stroke rehabilitation was monitored in their homes. The study was neutral in primary outcome however the lessons learnt from this trial will pave way for better home based stroke rehabilitation programs. The RECOVER trial was a simple pragmatic trial which tested the effectiveness of nurse driven stroke rehabilitation in China. The trial did not improve the patients outcome however the model was feasible in delivering rehabilitation. There are several small stroke rehabilitation trials which address specific functional disability. The assessment tools, outcome measures and culturally relevant therapies need to be considered when pragmatic stroke rehabilitation trials are designed.

  Symposium on Gait Disorder Rehabilitation Top

  Gait rehab in Ataxia Top

John M. Solomon1,2

1Department of Physiotherapy, Manipal College Health Professions, Manipal Academy Higher Education, 2Centre for Comprehensive Stroke Rehabilitation and Research, MAHE, Manipal, Karnataka, India

Gait training in cerebellar ataxia

Introduction: Cerebellar Ataxias are a group of gait disorders caused due to the dysfunction of the cerebellum due to inherited and acquired causes, manifesting as problems with balance and walking leading to considerable disability.[1] The cerebellar vermis [lays a significant part in controlling the gait by regulating extensor tone, sustaining upright stance and dynamic balance control, and modulating rhythmic flexor and extensor muscle activity.[2] But there seems to be contribution from the intermediate and lateral portions of the cerebellum in controlling precision and adjustments during novel situations respectively.[3] Hence lesion in any of these areas could lead to Ataxic gait. Traditional training methods: Gait training for cerebellar ataxia has been traditionally implemented along with Frenkel's exercise. Which follows the principles of precision, concentration and repetition. It involves, drawing foot print on the ground and training patients to place the feet on the marking and train them to control the foot placements. It has shown to improve functional balance and gait in patients with cerebellar disorders. Though it is widely practiced, it is often stereotypical, non-contextual and low of repetition in clinical setup based training. Here we look at other possible options to train patients with cerebellar ataxia. System based approaches: Affected anticipatory control while walking has been identified as one of the dysfunctions of cerebellar ataxia. Repeated waist pull perturbations[5] and use of obstacles could be used to control while walking. Trunk stabilization exercises to improve truncal stability has also been tried to reduce the ataxic component.[6] Task specific training: Task specific training in the form of Body Weight Support Treadmill training and Overground walking training has been used for improving gait parameters.[7],[8] Additional methods focus on use of various surfaces and walking environment. Gait adaptability training in these patients seem to improve their ability to avoid obstacles and gain more stability.[9] For any of these treatment to have an effect intensive training seems to be the key[10] There has also been trials looking at tasks that might transfer its benefit to walking, like climbing.[11] All these interventions are done under a trained therapists. But, would a homebased program work in these patients. Improvements in gait were noted in a study with a six week individualized home based balance exercise program for cerebellar ataxia.[12] Technology based interventions: VR/Game based rehabilitation and Robotics has gained popularity in improving balance and gait in patients with neurological disorders. Though studies seem to show some positive effects, these seem to be from the additional training received rather than a direct effect. More studies are needed before converting this into clinical practice for patients with ataxia.[13],[14],[15]

Conclusion: Patients with cerebellar ataxia improve with training implemented through physical and occupational therapy.[16] Individualized, intensive, context specific task based gait training seems to appropriate for improving gait in patients with cerebellar ataxia. There is a need to conduct more RCTs to derive define conclusion to identify evidence and implement it.


  1. Buckley E, Mazzà C, McNeill A. A systematic review of the gait characteristics associated with cerebellar ataxia. Gait Posture 2018;60:154-63.
  2. Ilg W, Timmann D. Gait ataxia – Specific cerebellar influences and their rehabilitation. Mov Disord 2013;28:1566-75.
  3. Kelly G, Shanley J. Rehabilitation of ataxic gait following cerebellar lesions: Applying theory to practice. Physiother Theory Pract 2016;32:430-7.
  4. He M, Zhang HN, Tang ZC, Gao SG. Balance and coordination training for patients with genetic degenerative ataxia: A systematic review. J Neurol 2020; (doi: 10.1007/s00415-020-09938-).
  5. Aprigliano F, Martelli D, Kang J, Kuo SH, Kang UJ, Monaco V, et al. Effects of repeated waist-pull perturbations on gait stability in subjects with cerebellar ataxia. J Neuroeng Rehabil 2019;16:50.
  6. Freund JE, Stetts DM. Use of trunk stabilization and locomotor training in an adult with cerebellar ataxia: A single system design. Physiother Theory Pract 2010;26:447-58.
  7. Im SJ, Kim YH, Kim KH, Han JW, Yoon SJ, Park JH. The effect of a task-specific locomotor training strategy on gait stability in patients with cerebellar disease: A feasibility study. Disabil Rehabil 2017;39:1002-8.
  8. de Oliveira LA, Martins CP, Horsczaruk CH, da Silva DC, Vasconcellos LF, Lopes AJ, et al. Partial body weight-supported treadmill training in spinocerebellar ataxia. Rehabil Res Pract 2018;2018:7172686.
  9. Fonteyn EM, Heeren A, Engels JJ, Boer JJ, van de Warrenburg BP, Weerdesteyn V. Gait adaptability training improves obstacle avoidance and dynamic stability in patients with cerebellar degeneration. Gait Posture 2014;40:247-51.
  10. Ilg W, Synofzik M, Brötz D, Burkard S, Giese MA, Schöls L. Intensive coordinative training improves motor performance in degenerative cerebellar disease. Neurology 2009;73:1823-30.
  11. Stephan MA, Krattinger S, Pasquier J, Bashir S, Fournier T, Ruegg DG, et al. Effect of long-term climbing training on cerebellar ataxia: A case series. Rehabil Res Pract 2011;2011:525879.
  12. Keller JL, Bastian AJ. A home balance exercise program improves walking in people with cerebellar ataxia. Neurorehabil Neural Repair 2014;28:770-8.
  13. Wang RY, Huang FY, Soong BW, Huang SF, Yang YR. A randomized controlled pilot trial of game-based training in individuals with spinocerebellar ataxia type 3. Sci Rep 2018;8:7816.
  14. Belas Dos Santos M, Barros de Oliveira C, Dos Santos A, Garabello Pires C, Dylewski V, Arida RM. A comparative study of conventional physiotherapy versus robot – Assisted gait training associated to physiotherapy in individuals with ataxia after stroke. Behav Neurol 2018;2018:2892065.
  15. Kim HY, Shin JH, Yang SP, Shin MA, Lee SH. Robot-assisted gait training for balance and lower extremity function in patients with infratentorial stroke: A single-blinded randomized controlled trial. J Neuroeng Rehabil 2019;16:99.
  16. Fonteyn EM, Keus SH, Verstappen CC, Schöls L, de Groot IJ, van de Warrenburg BP. The effectiveness of allied health care in patients with ataxia: A systematic review. J Neurol 2014;261:251-8.

  Electromechanical-assisted training for walking after stroke Top

Julia Patrick Engkasan

Department of Rehabilitation Medicine, Universiti Malaya, Kuala Lumpur, Malaysia

The aim of this lecture is to provide a summary and commentary on the published Cochrane Review titled: Electromechanical-assisted training for walking after by Mehrholz et al.[1] which was published in Cochrane Database of Systematic Reviews (2020). Approximately 20% and 70% of stroke survivors remains in a wheelchair and had difficulty walking respectively. Thus improving walking ability is one of the top priorities for people who have impaired walking. In the past decade, electromechanical assisted gait training has gained popularity. Electromechanical gait training enables repetitive gait cycles and requires less effort from physiotherapists.

This Cochrane systematic review by Mehrholz et al. aims to determine whether electromechanical- and robot-assisted gait training versus normal care improves walking after stroke. They also aim to determine whether electromechanical- and robot-assisted gait training versus normal care after stroke improves walking velocity, walking capacity, acceptability, and death from all causes until the end of the intervention phase.

This review addressed participants of any gender over 18 years of age after stroke. The interventions studied evaluated electromechanical- and robot- assisted gait training plus physiotherapy versus physiotherapy (or usual care) for regaining and improving walking after stroke. The intervention included were all types of electromechanical- and robot-assisted gait training, which is compared to conventional gait therapy. The primary outcome measure was the ability to walk independently. The secondary outcomes were walking speed (in metres per second; Hornby 2020), walking capacity (metres walked in 6 minutes;

This review included 62 trials involving a total of 2440 participants. In general, electromechanical-assisted gait training in combination with physiotherapy increased the odds of participants becoming independent in walking and increased mean walking velocity but did not improve mean walking capacity. The speaker will further describe the concept of sensitive and subgroup analysis used in this review. The lecture ends with describing how the evidence obtained from this systematic review could be put into clinical practice.


  1. Mehrholz J, Thomas S, Kugler J, Pohl M, Elsner B. Electromechanical-assisted training for walking after stroke. Cochrane Database Syst Rev 2020;10:CD006185.

  Symposium on Multiple Sclerosis Top

  Neurorehabilitation in multiple sclerosis – Building resilience based on neuroplasticity Top

Jürg Kesselring

Rehabilitation Centre, 7317 Valens, Switzerland

Neurorehabilitation – applied neuroplasticity. Re-organisation of structures and functions in the brain are the basis of learning. Plastic changes occur in normal as well as in diseased brains and can be enhanced by task-specific therapeutic interventions (Neurorehabilitation). Due to the variety of symptoms and functional deficits Multiple Sclerosis (MS) can lead to a broad range of functional impairments and handicap. Even with newer immunomudulating therapies, the course remains progressive. The symptoms themselves, loss of independence and participation in social activities are responsible for the progressive decline of quality of life. The main objective of a comprehensive rehabilitation program is to ease the burden of disease by improving self performance and independence. Restoration of function is not the key effect of rehabilitation in MS. As rehabilitation measures have no direct influence on the ongoing disease process and progression of the disease, compensation of functional deficits, adaptation and reconditioning together with other nonspecific effects (management of specific symptoms and impairments, emotional coping, self estimation) is more important in the longterm. Several of the many symptoms of MS are amenable to drug therapies which have been proven in careful evidence-based analyses to be effective (e.g. fatigue, spasticity, bladder, bowel and sexual disturbances, pain, cognitive dysfunctions etc). Newer studies in MS patients show, that despite the ongoing progression of the disease process, rehabilitation is effective by improving personal activities and participation in social activities leading to better quality of life. After comprehensive inpatient rehabilitation, improvement overlasts the treatment period for several months. Quality of life is correlated more with disability and handicap rather than with functional deficits and progression of the disease. Kesselring J, Comi G, Thompson AJ Multiple Sclerosis – functional recovery and neurorehabilitation Cambridge University Press 2010 Serafin Beer, Fary Khan, Jürg Kesselring Rehabilitation interventions in Multiple Sclerosis An overview J Neurol 2012 DOI 10.1007/s00415-012-6577-4 Kesselring J, Beer S Symptomatic therapy and Neurorehabilitation in multiple sclerosis The Lancet Neurology 2005; 4 (10); 643-652 Fary Khan, Bhasker Amatya, Mary P. Galea, Roman Gonzenbach, Jürg Kesselring Neurorehabilitation - Applied Neuroplasticity J Neurol 2016 (online 18.10.2016) Meyer-Heim A, Rothmaier M, Weder M, Kool J, Kesselring J Advanced cooling - garment technology: functional improvements in thermosensitive patients with Multiple Sclerosis 2006; 12: 1 – 6 Kesselring J, Coenen M, Cieza A, Thompson A, Kostanjsek N, Stucki G Developing the ICF Core Sets for Multiple Sclerosis to specify functioning Multiple Sclerosis 2008;14: 252-4 Holper, Coenen M, Weise A, Stucki G, Cieza A, Kesselring J Characterizing functioning in MS using the ICF J Neurol 2010; 257: 103 – 113 Prof. Dr. Jürg Kesselring is Head emeritus of Department of Neurology & Neurorehabilitation at the Rehabilitation Centre in Valens, Switzerland and Professor of Clinical Neurology and Neurorehabilitation, University of Bern, Lecturer in Clinical Neuroscience at the Center of Neuroscience, University and ETH Zürich, Chair of neurorehabilitation, San Raffaele University, Milano, Italy and at Danube University, Krems, Austria. He is a Member of the Assembly of the International Committee of the Red Cross, and former President (now: Honorary President) of the Swiss Multiple Sclerosis Society and former Chairman of the International Medical and Scientific Board of Multiple Sclerosis International Federation (MSIF) and of the Resarch Committee on Demyelination of the World Federation of Neurology (WFN), Chairman of the WHO Working Group on Multiple Sclerosis (-2005), former President of the European Committee on Treatment and Research in Multiple Sclerosis (ECTRIMS). Author of 250 Originalpublications and Editor or Co-Author of 15 books, mainly related to Multiple Sclerosis, Neurorehabilitation, Magnetic Resonance.

  COVID-19 and acute neurorehabilitation: An early mobilization program Top

Karin Disrens

Department of Clinical Neurosciences, Acute Heurorehabilitation Unit, University Hospital of Lausanne, Lausanne, Switzerland

Coronavirus disease 2019 (COVID-19) requires admission to the intensive care (ICU) for the management of acute respiratory distress syndrome in about 5% of cases. Although our understanding of COVID-19 is still incomplete, a growing body of evidence is indicating potential direct deleterious effects on the central and peripheral nervous systems. Indeed, complex and long-lasting physical, cognitive, and functional impairments have often been observed after COVID-19. Early (defined as during and immediately after ICU discharge) rehabilitative interventions are fundamental for reducing the neurological burden of a disease that already heavily affects lung function with pulmonary fibrosis as a possible long-term consequence. In addition, ameliorating neuromuscular weakness, with early rehabilitation would improve the efficiency of respiratory function as respiratory muscle atrophy worsens lung capacity. In this respect, we propose a neurosensory approach of verticalization using robotic devices associated with repetitive movements of the legs, allowing coma patients to improve awakening and re-afferentation. The benefits of early multidisciplinary rehabilitation after an ICU stay have been shown in several clinical conditions making an early rehabilitative approach generalizable and desirable to physicians from a wide range of different specialties and especially now for the polymorphic manifestations of COVID-19.

  Pitfalls of coma diagnosis: An interactive learning tutoria Top

Karin Diserens

Department of Clinical Neurosciences, Division of Neurology, Acute Neurorehabilitation Unit, University Hospital, Lausanne, Switzerland

Bedside assessment of consciousness or awareness after a severe brain injury might be hampered by confounding clinical factors (i.e., pitfalls) interfering with the production of behavioral or motor responses to external stimuli. Despite the use of validated clinical scales, a high misdiagnosis rate is indeed observed in severe brain injury patients admitted to an acute neuro-rehabilitation program. In this interactive learning tutorial, the main pitfalls are presented including polyneuropathy and/or myopathy and/or myelopathy, major cranial nerve palsies, non-convulsive status epilepticus, aphasia (expressive or comprehensive), cortical blindness, thalamic involvement and frontal akinetic syndrome. As all of these pitfalls could compromise the motor efference and verbal responses, which are mainly evaluated by the current clinical scales. In order to avoid confusing unresponsiveness with disorders of consciousness, the validated scales have to be complemented by observing the motor behavior and detecting subtle clues or conscious perception as signs of clinical 'Cognitive Motor Dissociation' (cCMD). We present a validated methodology called the Motor Behavior Tool (MBT) to detect cCMD using videos of clinical cases, and a treatment program using a neurosensorial approach in the very acute phase of these patients. We discuss the results of the outcomes of this particular subset of CMD patients.

  Gastrointestinal autonomic dysfunction in neurological disorders Top

Katarina Ivana Tudor

Department of Neurology, Unit for Headaches, Neurogenic Pain and Spinal Disorders, University Hospital Center Zagreb, Zagreb, Croatia

Bowel dysfunction is frequent among patients with neurological disease, e.g., spinal cord injury, multiple sclerosis, spina bifida, Parkinson's disease and stroke. These symptoms are among the most physically, socially and emotionally disabling. They have a major negative effect on the quality of life, ability to socially integrate and the ability to live independently. The aim of this talk is to review the pathophysiology underpinning gastrointestinal autonomic dysfunction in neurological disorders, assessment and management.

  Digital devices and cyberspace in neurorehabilitation Top

Lakshmi Narasimhan Ranganathan, Guhan Ramamurthy, R. Shrivarthan

Neurologist, Consultant Neurologist, Madras Medical College,

Tamil Nadu, India


The neurological disorders constitute a significant proportion of global disease burden and disability-adjusted life years, the majority of which is contributed by stroke and trauma in adults. Despite conventional rehabilitation, a vast majority of these patients fail to resume social and economic activities and lack of financial freedom. The emerging technologies can help to bridge the gap in enabling the effective functioning of the affected patient. It is brought about by augmented clinical improvement or replacing the function with substitution devices thereby negating the disability. In the following discussion, cutting edge treatment and rehabilitation with the following are discussed [Figure 1]:
Figure 1: Digital devices and cyberspace in neurorehabilitation

Click here to view

  • Neuromodulation
  • Sensory substitution devices
  • Cyberspace
  • Wearables
  • Neuromodulatio

The techniques in neuromodulation result in modulation of the neurons causing alterations in the excitability of the cortex, neuroplasticity and thereby brings about change in network behaviour. Neuroplasticity improves the adaptability of the brain to the pathological state resulting in improved function. This results from improved structural and functional efficiency of the neuronal process and remapping of the cortical maps following the insult. Neuromodulation is invasive or non-invasive. The invasive neuromodulation includes deep brain stimulation, invasive vagal nerve stimulation and epidural motor cortex stimulation. The non-invasive neuromodulation includes transcranial direct current stimulation (tDCS), transcranial magnetic stimulation (TMS), and paired associative stimulation (PAS).[1]

Invasive brain stimulation is useful in the management of various neurological disorders such as the use of deep brain stimulation in movement disorders, invasive vagal nerve stimulation in the management of drug-refractory epilepsy and epidural motor cortex stimulation in the management of pain. Non-invasive brain stimulation is based on the correction of interhemispheric imbalance following insult in one hemisphere. This is accomplished by stimulating the injured cortex or inhibiting the healthy cortex and resuming the balance between the two hemispheres. The stimulation of the ipsilesional cortex is performed using high-frequency repetitive TMS > 3Hz, anodal tDCS or PAS with an interstimulus interval of 25ms. Inhibiting the contralesional cortex is performed using low-frequency repetitive TMS < 1 Hz, cathodal tDCS or PAS with an interstimulus interval of 10ms, [Figure 2].[1]
Figure 2: The interhemispheric imbalance is corrected by stimulating the injured cortex or inhibiting the healthy cortex and resuming the balance between the two hemispheres. The stimulation of the ipsilesional cortex is performed using high frequency repetitive transcranial magnetic stimulation (TMS) >3Hz, anodal transcranial direct current stimulation (tDCS) or Paired associative stimulus (PAS) with an interstimulus interval (ISI) of 25ms. Inhibiting the contralesional cortex is performed using low-frequency repetitive TMS < 1 Hz, cathodal tDCS or PAS with an interstimulus interval of 10ms

Click here to view

The tDCS is performed by delivery of a constant and low-intensity galvanic current to the target area of interest. Anodal tDCS is stimulatory and cathodal tDCS is inhibitory. The evidence for the efficacy of the non-invasive brain stimulation has been mixed owing to the heterogenous methodology in various studies. Various evidence suggests the role of tDCS in the rehabilitation of motor and language deficits, hemineglect and post-traumatic disorders of consciousness [2],[3],[4],[5],[6]. The repetitive TMS (rTMS), using repetitive pulses of magnetic stimulation is useful in the rehabilitation of motor deficit, language deficit and hemineglect [7],[8],[9]. In PAS, a peripheral site of stimulation such as a median nerve is performed in conjunction with the central cortical stimulation performed using rTMS. When the interstimulus interval is > 25ms, it is excitatory and when the interstimulus interval is < 10ms, it is inhibitory. PAS, in the preliminary stages, was found to be useful in motor rehabilitation following stroke and spinal cord injury.[10],[11] Additional studies are required to establish the various target sites and dosages in motor and language rehabilitation.

Sensory Substitution Devices

Vision is a major sensory system that helps a subject navigate. The loss of sight results in significant disability to the patient. The use of several methods in visual restoration such as transplantation of photoreceptors, bionic eyes have proved futile. The emergence of sensory substitution devices has offered promise to the visually challenged. The sensory substitution device (SSD) functions by homing the visual information through auditory or tactile tracts and directs it to the visual cortex. The information is used to create mental images of the scene rather than a 'true vision'. The subjects can decipher the whereabouts of the objects and the properties of the surface encountered. The use of the SSDs has been based on the hypothesis that the brain is a task-specific structure and not modality-specific. The hypothesis is exemplified by the following scenarios. In a congenitally blind individual, an attempt to read using the braille system activates the visual word form area (VWFA) in the cortex similar to that would be activated in subjects reading through vision. Hence, VWFA is activated in the cortex for reading words regardless of the modality used. Similarly in subjects using echolocation, the visual cortex is activated as opposed to the activation of the auditory cortex for other sounds.[12]

The sensory substitution devices have been upgraded with the evolution of technology and are now available in mobile phones. For example, 'the vOICe' SSD application is useful in the conversion of visual information (using the camera) into auditory information (conveyed using the earphones to the subject). As the computer algorithms advance, the salient features from the scene can be filtered and converted into audio information. Following the training of individuals using the SSD, congenitally blind individuals and blindfolded normal sighted individuals were able to identify the location, size and texture of the objects in front, identify the movement of the objects and were able to navigate avoiding the obstacles. These results are promising in restoring the virtual sight in visually challenged individuals and encouraging the development of newer devices with easy interpretation of the stimuli and compact design of the device that can fit into the daily routine. The combination of retinal prosthesis and SSDs in restoring vision needs to be evaluated.[12],[13]


Cyberspace or the virtual space created by the cyber brain is an emerging tool in the armamentarium of neurorehabilitation. The virtual environment with a wide spectrum of interactions provides a tailored situation for the rehabilitation sessions. Virtual reality (VR) is immersive, semi-immersive or non-immersive. In non-immersive VR, the interaction is with a computer screen using a mouse and keyboard. In immersive VR, the patient is placed in a virtual environment using a head-mounted display. The various devices that are required to provide a completely immersive experience include a head-mounted display (at least 15 frames per second), omnidirectional treadmills, spatial sound, sensory vests and gloves for haptic input and interaction with surroundings respectively. The devices are used to place the patient in a suitable virtual environment with challenges relevant to the disability of the patient and training is initiated.[14]

Several studies are available on the use of virtual reality in various aspects of neurorehabilitation such as gait and balance, arm rehabilitation, cognitive rehabilitation and pain management. The studies have confirmed the feasibility and safety of the use of virtual reality in the patient population. The balance and gait training using virtual reality was found to reduce falls and improves balance scores in Parkinson's disease, improves balance scores in patients with multiple sclerosis and strengthens balance and gait speed in stroke patients. When VR is combined with treadmill training in Parkinson disease patients, it enhances biofeedback and reduces falls.[15]

VR in arm rehabilitation using task-specific game-based rehabilitation has shown improved functional outcomes in post-stroke patients. The visual amplification of the arm movement in the virtual reality platform that is oriented towards the goal, akin to mirror therapy, provides visual and motor feedback. This enhances motor recovery in stroke patients with hemiparetic arm.[16],[17]

The advantage of virtual reality in neurorehabilitation includes providing a safe environment, motivation to the patient and confidence, absent physical consequences from errors. Quantitative measurement of the improvement may be performed, and biofeedback can be provided to the patient that augments the recovery process. However, the available evidence has been focusing more on non-immersive VR. More studies using immersive VR, dosing and duration is the need of the hour.[14]


Wearables are digital devices worn on the patient body that helps collect the required information using sensors in monitoring the patient and provides feedback to the physician and the patient. It enables the continuous monitoring extending from the clinics to the home of the patient and ensures an objective measure rather than subjective description by the patient and thereby tailor the rehabilitative therapy to the patient.[18]

Inertial measurement units (IMU) measure the movement of limbs. The linear movement is measured using linear accelerometers and angular acceleration using a gyroscope. It provides an objective measure of the motor function during the activities of daily living at home. It records the movement intensity, amplitude and frequency that provide clinical information to the physician and feedback to the patient. The potentiometers are used to measure the angular displacement and hence detects the movement range of the joint. Encoders are digital versions of potentiometers.[18]

Surface Electromyography (sEMG) sensors are useful in recording the muscle activity and pattern of muscle activation involved in the movement. It complements the data collected by the IMU in the assessment of motor activity. The data collected include recording the strength of contraction of the involved muscles and the fine movements involved in the handling of objects. A device setup with the use of the above sensors helps collect data in making clinical decisions. These sensors are being studied in the rehabilitation of stroke patients.[18]


The use of digital devices including neuromodulation, SSD and wearables are set to revolutionize the assessment and rehabilitation of patients with motor and cognitive deficits. Cyberspace can provide a safe environment and fabulous platform for the rehabilitation of patients. With the evolution and digitalization of the world, these devices will become more affordable and widely used. However, the literature studies and data on these technologies is far from adequate. A uniform protocol for studies is required to compare devices across studies and to establish the dosing and duration of the rehabilitation.


  1. Castel-Lacanal E. Sites of electrical stimulation used in neurology. Ann Phys Rehabil Med 2015;58:201-7.
  2. Elsner B, Kugler J, Pohl M, Mehrholz J. Transcranial direct current stimulation (tDCS) for improving function and activities of daily living in patients after stroke. Cochrane Database Syst Rev 2013;11:CD009645.
  3. Monti A, Cogiamanian F, Marceglia S, Ferrucci R, Mameli F, Mrakic-Sposta S, et al. Improved naming after transcranial direct current stimulation in aphasia. J Neurol Neurosurg Psychiatry 2008;79:451-3.
  4. Vestito L, Rosellini S, Mantero M, Bandini F. Long-term effects of transcranial direct-current stimulation in chronic post-stroke aphasia: A pilot study. Front Hum Neurosci 2014;8:785.
  5. Sunwoo H, Kim YH, Chang WH, Noh S, Kim EJ, Ko MH. Effects of dual transcranial direct current stimulation on post-stroke unilateral visuospatial neglect. Neurosci Lett 2013;554:94-8.
  6. Angelakis E, Liouta E, Andreadis N, Korfias S, Ktonas P, Stranjalis G, et al. Transcranial direct current stimulation effects in disorders of consciousness. Arch Phys Med Rehabil 2014;95:283-9.
  7. Hsu WY, Cheng CH, Liao KK, Lee IH, Lin YY. Effects of repetitive transcranial magnetic stimulation on motor functions in patients with stroke: A meta-analysis. Stroke 2012;43:1849-57.
  8. Ren CL, Zhang GF, Xia N, Jin CH, Zhang XH, Hao JF, et al. Effect of low-frequency rTMS on aphasia in stroke patients: A meta-analysis of randomized controlled trials. PLoS One 2014;9:e102557.
  9. Kim BR, Chun MH, Kim DY, Lee SJ. Effect of high- and low-frequency repetitive transcranial magnetic stimulation on visuospatial neglect in patients with acute stroke: A double-blind, sham-controlled trial. Arch Phys Med Rehabil 2013;94:803-7.
  10. Castel-Lacanal E, Marque P, Tardy J, de Boissezon X, Guiraud V, Chollet F, et al. Induction of cortical plastic changes in wrist muscles by paired associative stimulation in the recovery phase of stroke patients. Neurorehabil Neural Repair 2009;23:366-72.
  11. Bunday KL, Perez MA. Motor recovery after spinal cord injury enhanced by strengthening corticospinal synaptic transmission. Curr Biol 2012;22:2355-61.
  12. Reich L, Maidenbaum S, Amedi A. The brain as a flexible task machine: Implications for visual rehabilitation using noninvasive vs. invasive approaches. Curr Opin Neurol 2012;25:86-95.
  13. Jicol C, Lloyd-Esenkaya T, Proulx MJ, Lange-Smith S, Scheller M, O'Neill E, et al. Efficiency of sensory substitution devices alone and in combination with self-motion for spatial navigation in sighted and visually impaired. Front Psychol 2020;11:1443.
  14. Schiza E, Matsangidou M, Neokleous K, Pattichis CS. Virtual reality applications for neurological disease: A review. Front Robot AI 2019;6:100.
  15. Cano Porras D, Siemonsma P, Inzelberg R, Zeilig G, Plotnik M. Advantages of virtual reality in the rehabilitation of balance and gait: Systematic review. Neurology 2018;90:1017-25.
  16. Shin JH, Ryu H, Jang SH. A task-specific interactive game-based virtual reality rehabilitation system for patients with stroke: A usability test and two clinical experiments. J Neuroeng Rehabil 2014;11:32.
  17. Ballester BR, Nirme J, Duarte E, Cuxart A, Rodriguez S, Verschure P, et al. The visual amplification of goal-oriented movements counteracts acquired non-use in hemiparetic stroke patients. J Neuroeng Rehabil 2015;12:50.
  18. Maceira-Elvira P, Popa T, Schmid AC, Hummel FC. Wearable technology in stroke rehabilitation: Towards improved diagnosis and treatment of upper-limb motor impairment. J Neuroeng Rehabil 2019;16:142.

  Symposium on Holistic Rehabilitation Top

  Eight weeks of high-intensity interval static strength training improves skeletal muscle atrophy and motor function in aged rats Top

Lei Fang

Associate professor of School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine

Background: Sarcopenia is a syndrome characterized by the loss of skeletal muscle mass and strength. Most studies have focused on dynamic resistance exercises for preventing muscular decline and maintaining the muscle strength of older individuals. However, this training mode is impractical for older people with osteoarthritis and a limited range of motion. The static strength training mode is more suitable for older people. Therefore, a determination of the effect and mechanism of static strength training on sarcopenia is critical.

Methods: In this study, we developed a training device designed to collect training data and evaluate the effects of static training on the upper limbs of rats. The expression of PGC-1 was locally blocked by injecting a siRNA at the midpoint of the biceps to determine whether PGC-1 signal transduction participates in the effects of high-intensity interval static training on muscle strength. Then, the rat's motor capacity was measured after static strength training. Immunohistochemistry and Western blotting were applied to determine PGC-1 /FNDC5/UCP1 expression levels in the muscle and adipose tissue. The serum irisin level was also detected using an enzyme-linked immunosorbent assay (ELISA).

Results: Increased levels of serum irisin and local expression of FNDC5, PGC-1, and UCP1 were observed in the biceps brachii and surrounding fatty tissue after static strength training. Static strength training showed an advantage in reducing body weight and white fat accumulation while increasing the muscle fiber volume, which resulted in a longer training time and shorter rest time.

Conclusion: Overall, these results indicated that high-intensity interval static training prevents skeletal muscle atrophy and improves the motor function of aged rats through the PGC-1/FNDC5/UCP1 signaling pathway.

  Invited Guest Lecture Top

  Setting goals in neurorehabilitation with ICF and WHODAS 2.0 Top

Leonardi Matilde

Orthotist & Prosthetist, Director,Fondazione IRCCS Istituto Neurologico C. Besta

Whenever a patient's problems are sufficiently complex to require the involvement of a two or more service providers from different professions and/or the process is continued for more than a few days, then a formal goal-setting process may be needed to derive a set of goals that motivate the patient; ensure that individual team members work towards the same goals; ensure that important actions are not overlooked; and allow monitoring of change to abort ineffective activities quickly. ICF and WHODAS 2.0 are the instruments that can help professional to set goals for neurorehabilitation of patients all over the world. A common language is what is needed and ICF can provide it.

  Symposium on Holistic Rehabilitation Top

  Focused ultrasound and neuromodulation Top

Lijuan Ao

Professor & Dean of School of Rehabilitation, Kunming Medical University, Yunnan, 650500

1. Brief introduction of focused ultrasound (FUS) Human can hear sounds within frequency from 20 Hz to 20,000 Hz. The frequency of ultrasound is above 20,000 Hz so that cannot be perceived by human and has long been widely used in clinical practice as imaging methodology and physiotherapy. Focused ultrasound is namely ultrasound that works in a focused way. The most frequently used analogy of FUS is a magnifying glass which can focus sun rays into a point. Under this condition, combustible can be fired easier within the focused point rather than other regions. Since the discovery that sound could interact with biological organ as well as tissue more than 100 years ago, researchers devoted into biophysical effects of sound and FUS has aroused researchers' interests in neuromodulation for the past decades. It has been well known that under certain parameters, if the focus of high-intensity focused ultrasound (HIFU) is put at deep biological tissue, thermal ablation occurs in the focused region while the surrounding tissue remains unaffected. In the year of 2016, the U.S. Food and Drug Administration approved the first focused ultrasound device to treat drug non-responsive essential tremor via thermal ablation. Apart from thermal ablation, the blood-brain barrier (BBB) could be reliably, transiently and locally opened via low-intensity focused ultrasound (LIFU) with the appearance of microbubbles. The blood-brain barrier exists between blood circulation and brain tissue, and is responsible for protecting the brain from toxins, which on the other hand hinders therapeutic agents into the brain, becoming an obstacle of CNS disease treatment. BBB opening via FUS and microbubbles creates conditions for neuromodulations such as delivery of anticancer drugs, genes and other therapeutic agents. LIFU alone, however, has exerted its potential of modulating neuro activities in numerous researches. LIFU has been reported to excite and inhibit neuros reversibly, which may benefit for diseases such as Parkinson's disease and neuropathic pain. 2. Biophysical effects of FUS How FUS interacts with neuros is of great significance to understand the principle behind neuromodulation via FUS, but it's far to get an acknowledged biophysical mechanism theory. The biophysical effects of FUS can be conventionally categorized into thermal effects and non-thermal effects. At high intensities, FUS is able to locally increase temperatures as to denature proteins and coagulation necrosis occur eventually (>56). So far HIFU ablation has been reported promising benefits for fibroids, essential tremor, Parkinson's disease, obsessive-compulsive disorder, major depression and even chronic neuropathic pain. At low intensities, thermal effect of FUS becomes subordinate, the temperature changes is minimal within physiological range, and non-thermal effects play a leading role. Non-thermal effects of FUS include mechanical pressure, radiation force, and cavitation, among which cavitation plays an important role in BBB opening via LIFU. When microbubbles circulate through the focused region, FUS activates microbubbles to grow, oscillate (stable cavitation) and even collapse (inertial cavitation), affecting cellular structure and leading to the open of tight junctions of BBB, which facilitates drugs delivery into the brain. When the pressure is reduced by ultrasound or under negative pressure, sub-micron gas particles in body fluids may separate from hydrophobic substances and expand to form gas microbubbles. Stable cavitation is theorized to move bilayer membrane without pre-injunction microbubbles and affect cellular membrane potentials via mechanosensitive proteins. What's more, study has demonstrated that local application of FUS radiation force causes tissue replacement, which in theory will affect mechanosensitive ion channels and eventually change activity state of neuros. 3. Applications of FUS neuromodulation At present, the commonly used neuromodulation methods include deep brain stimulation (DBS), transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS). Deep brain stimulation (DBS) is a surgical neuromodulation procedure that need electrode implanted into certain regain to block abnormal neural activities. One of disadvantages of DBS is its invasive nature, which accordingly increases the risk of inflammation. TMS as well as tDCS are noninvasive. TMS can effect at the surface of the brain with centimeter-level, while FUS can achieve millimeter or even submillimeter resolution. The same as TMS, tDCS possesses unsatisfied anatomical resolution. FUS is emerging as an innovative neuromodulation methodology. The advantages of FUS neuromodulation are attractive: noninvasive, high resolution, the compatibility with other imaging methodology such as MRI which facilitates real-time location and monitoring during FUS procedure. These advantages are driving FUS toward disease-treating researches and clinical practice. As one of the most common movement disorders, essential tremor is a highly disabling disease, with incidence estimated at 0.3-5.6%, and the incidence increases with age. For patients with essential tremor who have not respond to medications, surgical treatment, usually thalamotomy may be consider and FUS is one of the alternative choices. Studies have demonstrated the effectiveness as well as feasibility of transcranial FUS ablation in treating essential tremor. Elias et al. carried out MRI-guided FUS thalamotomy on 57 patients with other 19 patients treated sham procedure. The mean score for hand tremor improved by 47% at 3 months. With the promising effect of FUS ablation on essential tremor, MRI-guided FUS ablation has been approved by U.S. Food and Drug Administration to treat essential tremor and the approval to treat Parkinson's disease is pending. Parkinson's disease (PD) is a progressive neurodegenerative disease. Tremor, bradykinesia, stiffness and postural instability are common symptoms of PD. The symptoms can be alleviated by medications while the neurodegeneration progress cannot be stopped. Studies of dealing PD with FUS involve ablation, BBB opening and the stimulation of brain circuits. Thalamotomy of the ventral intermediate nucleus via MRI-guided FUS ablation significantly reduced PD patients' tremor and increased the quality of life. BBB opening can serve as an effective gene therapy strategy. Delivery of glial cell line-derived neurotrophic factor (GDNF) gene exerted neuroprotective effect and improved motor-related behavioral abnormalities in a muse model of PD. Recently a study reveals that noninvasive deep brain stimulation of the subthalamic nucleus or the globus pallidus via FUS improves motor function of PD mice and protects the dopamine neurons. As the most common neurodegenerative disorder, Alzheimer's disease (AD) posts great challenge to modern medicine. The situation of AD is similar to PD, that is there are symptom-relief medications but no curative approach exists. In 2010, a study of Jordão et al. provided evidence that BBB opening via MRI-guided FUS enhanced delivery of intravenously-administered antibodies and amyloid A plaque pathology was reduced in AD mouse model. A subsequent study further proved the value of BBB opening via FUS in AD. In this study, transcranial FUS BBB opening was carried out on TgCRND8 mouse model of AD, a reduction of plaque pathology was also observed without additional therapeutic agents administered. Endogenous antibodies are found bound to A plaques and glia activation was enhanced, which may contribute to internalization of A. Apart from disorders mentioned above, other diseases such as brain tumor, obsessive-compulsive disorder, major depression and even neuropathic pain also benefit from FUS ablation and opening of the BBB in various degree. 4. Our practice We are fascinated by the “magical” biophysical effects of FUS and have been working hard for years in therapeutic effects and the mechanism behind. Our published or on-going studies involve: (1) the effect and mechanisms of BBB opening with FUS. (2) lipid PLGA hybrid bubbles manufacturing. (3) treating diseases such as AD, PD and neuropathic pain via FUS. Our latest work demonstrated that LIFU is effective at alleviating neuropathic pain by increasing the expression of KCC2 and inhibiting of CaMKIV–KCC2 pathway in L4–L5 section of rats with peripheral nerve injury. We have been paying much endeavor seeking evidence about effectiveness of FUS in the treatment of interested disorders and will go for it continuously. 5. Conclusions FUS is becoming a candidate of cerebral surgery. thermal ablation of targeted nuclei may normalize brain activities so as to improve motor function such as essential tremor and Parkinson's disease. FUS induced BBB opening provides possibilities to delivery drugs which cannot easily access into the brain under physiological conditions. Increased permeability of BBB is a low-cost choice because of high utilization rate of therapeutic agents when dealing with cerebral tumors. The potential of stimulating and inhibiting neural activities makes FUS a possible candidate for movement disorders or even psychiatric illness. Overall, FUS is an innovative neuromodulation methodology. It is noninvasive, low-cost and precise. The improvement of FUS technics will move us further to understand mechanisms behind FUS and may revolutionize the way that people deal with neurological and psychiatric diseases.

Paediatric rehabilitation

Luh Karunia Wahyuni

Physiatrist, Head of PMR, RSCM-University of Indonesia

Children with disabilities are experiencing significant challenges to service access due to suspension of in-person medical rehabilitation management during the current COVID-19 pandemic. Access to routine but essential services for child health and development, such as developmental monitoring and support services, are very limited in this pandemic era. The impact of these service changes was compounded by the closure of services that provide therapeutic interventions, education, formal and informal supports. Simultaneously, families were dealing with additional stressors such as self-isolation/quarantine, fear of transmission, financial loss, inadequate food and medical supplies, relationship stress and stigma. Children are also experiencing loss of routines, frustration, boredom, lack of contact with close family members (e.g. grandparents) or friends. Even though restrictions are loosening, families are still reluctant to take their children to health facilities for non-urgent issues due to concern about viral exposure or in effort to minimise the burden of healthcare services. This is further exacerbating the 'inverse care law' that existed prior to the pandemic, in which those children from the most disadvantaged backgrounds and most at risk of disability are the ones least engaging and accessing the prevention and health promotion programmes. The COVID-19 pandemic represents a transformative shock to our health-care system. Understandably the initial focus has been on developing readiness for worst case infection burden and intensive care. There is now an urgent need to establish alternate support and intervention systems for vulnerable groups, with a recent report suggesting that children with disability are experiencing significant employment stress in the family. In accordance with the WHO call for 'keeping each other safe and connected', we need to examine the potential opportunities to build a service system so that children with disabilities, and their families, are not left behind. Innovative care delivery models must therefore be a focus of medical rehabilitation care services and policy initiatives during and following this COVID-19 pandemic. We must create true partnerships between parents and medical rehabilitation care services that focus primarily on improving access to medical rehabilitation care by reducing barriers of time and expense associated with travel and at the same time adhere to current health protocols. Telemedicine has become one of viable solutions to address the medical rehabilitation team shortages and geographic barriers that rural residents face and has been implemented successfully to provide specialist consultation for children with disabilities.

There are a few published reports describing the use of telemedicine for children with disabilities. The use of telemedicine has been reported to be particularly attractive and equally effective as in-person visits with a high satisfaction level. The reason being was because of (a) reduced travel costs and reduced time lost from work, (b) avoiding the need for special equipment or staff during travel, (c) decreasing stress for the child and parents, (d) increasing the likelihood of a successful examination and treatment by receiving care in a familiar environment with less disruption to their routine.

Indonesia, as the largest archipelago country in the world, has always had significant challenges in providing equal healthcare for the whole population of 276 million people spread across thousands of islands. Therefore, the use of telemedicine can be one of the answers for this problem. The government also showed support for telemedicine by the passing of The Indonesian Ministry of Health Regulation No. 20 of 2019 on Implementation of Telemedicine between Health Service Facilities. Based on the data from the Indonesian Ministry of Communications in 2020, approximately 150 million people in Indonesia are daily internet users (around 56% of the population). The fact that more than half of the population are using the internet, the use of telemedicine system is indeed promising.

Telemedicine has already been used in Indonesia to bridge some gaps in healthcare delivery for those who live outside the metropolitan areas, or in remote and rural areas. In recent years, online health care has also been growing, but many of the programmes are not yet optimized or targeted to children with a disability.

In conclusion, Indonesia need to learn from other countries' experiences and researches about their telemedicine system. In order to establish an effective telemedicine system that can provide medical rehabilitation services while still ensuring the quality and standards of care for children with disability, including the education and training of the staff.

Keywords: Children with disabilities, COVID 19, telemedicine

  Symposium on Dementia Top

  Dementia evaluation and rehabilitation in Japan: A neuropsychology perspective Top

Maiko Sakamoto Pomeroy

Orthotist & Prosthetist, Japan

Overview of Dementia in Japan It is well known that Japan has one of the longest life expectancies – the average life span for women is 87.45 years and men is 81.41 years.[1] The average life span of both men and women has extended more than five years in 30 years due to improvement in medical technologies as well as increased health awareness. As Japan is a super-aging society, dementia is an immensely serious issue including diagnosis, treatment, and care. As of 2020, six million people are living with dementia and is expected to increase to seven million by 2025, which indicates that one out of five elders (over 65) will be diagnosed with dementia.[1] Alzheimer's disease (AD) and vascular dementia (VaD) are the two most prominent dementia subtypes in Japan, and it was reported that VaD was more prevalent than AD until the 1990's. However, the number of AD is increasing whereas that of VaD is decreasing.[2] In 2019, approximately 68% of dementia patients were diagnosed with AD, 20% with VaD, 4.3% with Lewy body dementia, and 1% with frontotemporal dementia.[1] It is not uncommon to see that the family members who bring patients to the hospital are also elderly. This phenomenon is called, which means “older people looking after very old people.” It is a part of Japanese tradition to take care of aging parents, and we now see sons and daughters of patients who are over 65 and need their own medical care. In fact, I had a 98-year-old mother and 70-year-old daughter who both suffered from dementia. Thus, early diagnosis and early intervention is crucial for not only patients but also their families to maintain current cognitive and everyday functions. Dementia Evaluation in Japan Like most countries, we use a multidisciplinary approach to diagnose dementia. In general, patients undergo physical checkups, blood drawing and urine tests, neuropsychological tests, and imaging tests. The family members will be asked various questions including chief complaints (i.e., memory problems, dysexecutive functions, behavioral and psychological symptoms of dementia (BPSD) etc.) and patient's activities of daily living (ADL)/instrumental activities of daily living (IADL). Regarding neuropsychological tests, Mini-Mental Sate Examination (MMSE), Hasegawa Dementia Scale- Revised (HDS-R), and Montreal Cognitive Assessment (MoCA) are widely used as a screening tool in Japan; however, they cannot localize cerebral lesions or differentiate subtypes of dementia.[3] Frontal Assessment of Bedside (FAB), Trail Making Test (TMT), Clock Drawing Test (CDT), animal naming test, cube drawing, and Geriatric Depression Scale (GDS) are the examples added to assist differentiating subtypes of dementia. The Alzheimer's Disease Assessment Scale – Cognitive (ADAS-Cog) and Repeated Battery for the Assessment of Neuropsychological Status (RBANS) have been also used for both clinical and research settings. It is important to note that many neuropsychological assessments do not have standardized norms developed based on a large pool of the Japanese population; therefore, choice of tests is limited.[4] Evaluating IADL is challenging in Japan. It is ideal to conduct actual IADL assessments, such as Naturalistic Action Test (NAT); however, we lack examiners, time, and space within clinical settings.[4] As a result, we must rely on questionnaires, such as Lawton-Brody IADL scale, Functional Status Questionnaire (FSQ), and Clinical Dementia Rating (CDR). While it is easy to gather information in a relatively short time, these questionnaires tend to include subjective opinions. In addition, it is part of our culture that wives do most of the house chores, and as a result, it is not uncommon to see male patients who have never cooked, grocery shopped, did laundry, or even prepared their own clothes. This situation makes it difficult to compare their current IADL level to baseline (pre-dementia). Many Japanese men often focus on work; however, they are usually retired when they come to memory clinics, so we must evaluate based on limited information regarding IADL. One other factor that makes early diagnosis and early intervention challenging is our cultural aspect of overconfidence about the elders' cognitive function as well as a cultural stigma of mental and cognitive disorders.[4] Even if grown children recognize their parents' cognitive decline, they may not take the parents to memory clinics if they refuse to go. While it is recommended starting drug treatment and rehabilitation when the patient exhibits Mild Cognitive Impairment (MCI), it is not uncommon to see patients whose cognitive and IADL functions have already declined to a moderate level of dementia. Therefore, within the Japanese tradition of respecting and looking after the elderly, it ironically becomes an obstacle for dementia care. Rehabilitation for Japanese Dementia patients and Family Having personal goals in life can drastically reduce incidents of developing not only dementia but also MCI.[5] Thinking about the future and setting personal goals may increase their health awareness. Creating personal goals is one of the most important aspects in dementia rehabilitation. For example, Aid for Decision Making in Occupation Choice (ADOC) is an iPad application invented to help patients develop their personal goals.[6] The ADOC consists of 95 questions with pictures, and generally therapists help patients to work through ADOC. Given that the cut off score for the use of ADOC is seven points on MMSE, even moderately or severely impaired patients may be able to use this tool.[7] When making goals, it is important to make goals personable. Respecting the patient's opinions and focusing on 5W1H (who, why, what, when, where, and how) allows to develop customized and achievable goals.[8] The other important aspect in dementia rehabilitation is to assess relationships between cognition, IADL, BPSD, and other factors and evaluate them routinely. Problems tend to occur when the balance between cognitive and physical functions and living environment becomes disrupted.[8] These problems are usually not singular but intertwined; therefore, it is important to prioritize issues based on personal goals as well as emergency. Many approaches and techniques are used for dementia rehabilitation in Japan. Life Review/Reminiscence developed by Robert Butler[9] is one of the oldest techniques used in Japan. As many Japanese elders survived World War II and achieved economic development post-war successes, sharing painful experiences and happy memories help the patients reduce confusion and anxiety. Cognitive Simulation Therapy (CST), Cognitive Training (CT), and Cognitive Rehabilitation (CR) are newer and seen at nursing homes and adult day services.[8] For example, Japanese dementia patients participated in CST sessions twice a week for seven weeks and demonstrated significant improvement in cognitive function, mood, and Quality of Life (QOL).[10] Sudoku, Kumon, cross-word puzzles, and Wii are also often used at adult day services. Occupational therapy has been also used for dementia rehabilitation.[8] It targets improvements in IADL, QOL, BPSD, and caregivers' burden. Music therapy and animal therapy help dementia patients reduce anxiety and irritation, relax, and reminisce. Light exercise and nutrition therapy are also effective to improve patients' apathy, physical strength, and sleep dysfunction.[8] Nursing homes and adult day services in Japan combine these approaches and techniques based on the patients' cognitive and physical conditions as well as personal goals. Challenges for Dementia Care in Japan Due to the aging and decreasing birth rate, we are facing financial and elderly care crisis, and therefore, the elders' well-being and independence is important. In Saga prefecture, public halls invite local elders to activities, such as mahjong, Shogi, dance, swimming, and so forth for prevention of dementia and frail. In 2012 and 2015, the Japanese government proposed seven core plans to prevent and treat dementia, including training dementia supporters and care managers, developing local support teams, and opening “Dementia Cafés” as a gathering place for patients and their families to provide useful information and psychological support.[1] There are approximately 8,000 dementia cafes operating and expanding throughout Japan. Developing rehabilitation models and providing the services are among the seven plans; however, any rehabilitation approach requires professionals. For example, trained clinical psychologists or clinicians should conduct CST, CT, CR or Reminiscence because the sessions could be not only ineffective but dangerous, and the patient might have a traumatic experience. Thus, training dementia care professionals is one of the biggest challenges. New medication, Lecanemab, for AD was granted by the FDA, and this news gives us hope that AD may be cured one day. However, it is our common understanding that society will continue to cope with dementia. It is essential to facilitate dementia research, respect patients and their families, provide quality support and educate society as a whole on dementia.


  1. Minister of Health, Labour and Welfare. Comprehensive Promotion for Dementia Care; 2019. Available from: https://www.mhlw.go.jp/content/12300000/000519620.pdf.
  2. Nakamura S, et al. Prevalence and predominance of Alzheimer type dementia in rural Japan. Psychogeriatrics 2003;3:97-103.
  3. Matsuda H, Asada T, editors. Diagnostic Imaging for Dementia. Osaka, Japan: Nagai Syoten; 2004.
  4. Sakamoto M. Neuropsychology in Japan: History, current challenges, and future prospects. Clin Neuropsychol 2016;30:1278-95.
  5. Boyle PA, Buchman AS, Wilson RS, Yu L, Schneider JA, Bennett DA. Effect of purpose in life on the relation between Alzheimer disease pathologic changes on cognitive function in advanced age. Arch Gen Psychiatry 2012;69:499-505.
  6. Tomori K, Uezu S, Kinjo S, Ogahara K, Nagatani R, Higashi T. Utilization of the iPad application: Aid for Decision-making in Occupation Choice. Occup Ther Int 2012;19:88-97.
  7. Tomori K, Nagayama H, Saito Y, Ohno K, Nagatani R, Higashi T. Examination of a cut-off score to express the meaningful activity of people with dementia using iPad application (ADOC). Disabil Rehabil Assist Technol 2015;10:126-31.
  8. Tahira T, Tanaka H, editprs. Dementia Rehabilitation Based on Evidence. Tokyo, Japan: Igaku Shoin; 2020.
  9. Butler RN. The life review: An interpretation of reminiscence in the aged. Psychiatry 1963;26:65-76.
  10. Yamanaka K, Kawano Y, Noguchi D, Nakaaki S, Watanabe N, Amano T, et al. Effects of cognitive stimulation therapy Japanese version (CST-J) for people with dementia: A single-blind, controlled clinical trial. Aging Ment Health 2013;17:579-86.

  Symposium on Motor Neurone Disease Top

  Speech and swallowing disorders in MND Top

Mansi Jagtap

Assistant Professor, Bharati Vidyapeeth Deemed University, Pune, Maharashtra, India

Motor neuron disease is a group of conditions affecting the motor neurons which play a vital role in gross and fine motor skills. Speech and swallowing are complex functions which are governed by these neurons, and hence, can be impaired in individuals with MND affecting the bulbar region (head and neck region). Research reveals that 25% of patients with MND present with affected speech (dysarthria) and/or swallowing (dysphagia) skills at time of disease onset. These primarily stem due to affected oromotor structures (atrophy and wasting) and function (weakness, spasticity, reduced range of motion) like tongue, jaw, palate, lips as well as pharyngeal and laryngeal area. Mixed dysarthria of flaccid – spastic origin is frequently encountered due to involvement of upper and lower motor neurons. These involve multiple subsystems like respiration, phonation, resonance, articulation and prosody, leading to poor speech intelligibility. Oropharyngeal dysphagia poses health risks among patients with MND. Reduced speech intelligibility and oropharyngeal dysphagia affect the quality of life of these individuals. As MND is a progressive degenerative condition, a deterioration in the severity of dysarthria and dysphagia is commonly noted. Those patients who revealed normal speech and swallowing skills at disease onset may show bulbar symptoms as disease spreads and progresses to the head and neck region. Since the rate of progression is variable among patients, Speech language pathologists play a vital role in detailed and regular assessment of speech and swallowing functions so as to identify early signs of deterioration and plan appropriate intervention. Universally used scales like ALS functional rating scale, Norris scale provide valuable information on disease progression, however, should be cautiously interpreted with respect to bulbar functions as these are weighed more to evaluate overall motor functioning with lesser focus on speech and swallowing problems alone. Detailed assessment of speech sub systems, speech intelligibility and swallowing skills using standardized protocols are helpful in charting these functions more specifically. Intervention depends on various factors, especially the stage of disease. It could either aim to improve the function or facilitate compensation. In end stage cases however, palliative care in form of enteral feeding and alternative modes of communication are preferred when no meaningful speech and safe swallow is possible. SLP play an important role in determining candidacy for adequate intervention of speech and swallow functions. The presentation will focus on highlighting the salient features pertaining to speech and swallowing problems in individuals with MND and will touch upon intervention strategies for the same.

  Rehabilitation in Intensive Care Unit Top

  Follow-up of patients with post-acute covid syndrome through online telerehabilitation and non-immersive virtual reality Top

Marcos Maldonado, Josefina García Huidobro, Ricardo Vasquez

Department of Physical Medicine and Rehabilitation, Outpatient Neurorehabilitation Unit, Clinica Alemana - Universidad del Desarrollo. Santiago, Chile E-mail: [email protected]

Background: Covid-19 survivors, especially those who required ICU ventilatory support and with prolonged length of stay in ICU may develop residual deficits such as neuropathies, myopathies, and deconditioning critically illness seen as part of critical care episodes. Therefore, they are more likely to need ongoing rehabilitation. A classification was established by Nalbandian et al. that those patients whose symptoms were persistent, generating late or long-term complications. It was divided into two categories: (1) subacute or ongoing symptomatic COVID-19, which includes symptoms and abnormalities present 4 to 12 weeks after acute COVID-19; and (2) chronic or post-COVID-19 syndrome, which includes symptoms and abnormalities that persist or are present beyond 12 weeks from the onset of acute COVID-19 and not attributable to alternative diagnoses. There is concern regarding the effectiveness of rehabilitation, particularly if systematic evaluations are not carried out that will make it possible to know the evolution of recovery objectively. Therefore, the evaluation of functional capacity in these patients has become an important issue to estimate functional consequences, disability and desaturation during physical exertion. Although there are national and international guidelines that recommend specific evaluations and treatments, the evidence is still scant on how to perform virtual evaluations and treatments (including stress tests) in patients with cardiopulmonary disease. However, a recent systematic review concluded that many functional exercise tests can be performed virtually at home with minimal equipment (for example, 1 minute sit-and-stand (1-MSTST) tests, 4-meter walking speed (4MGS), battery Short Physical Performance Test (SPPB) and various step tests. It was determined that the 1-MSTST could be a practical, reliable, valid and responsive alternative to measure physical capacity, and has shown a significant correlation with clinical outcomes in subjects with lung disease and chronic obstructive disease. To carry out this therapy, tele-rehabilitation programs use appropriate technology that has the potential to help in situations like this. Patients must be offered a fast and easily accessible therapeutic method. This can be delivered in a number of ways, either synchronously or asynchronously, using non-immersive virtual reality (NIVR). The latter is less well known, but has proven to be effective as it meets several criteria: it provides cognitive-motor training, follows evidence-based neuroscience principles, offers motivational activities and empowerment techniques. This helps promote self-confidence, self-management, self-efficacy and, therefore, independence, promoting recovery and a higher quality of life for patients. Thus, the purpose of this study is to describe the experience of the home hospital rehabilitation care model for patients with post-acute covid syndrome, carried out through evaluation, intervention and follow-up through online tele-rehabilitation (OTR) and a non-immersive virtual reality program (NIVR)

Methods: This was a descriptive, retrospective study conducted in a private clinic in Santiago de Chile, with all patients with post-acute covid syndrome between March and May 2021. All were evaluated by a physiatrist prior to discharge, if met the rehabilitation objectives and the inclusion criteria (without ventilatory support, stable hemodynamics, FSS-ICU > 33, Medical Research Council (MRC) 4 or 5 in each muscle group), they were proposed to participate in the study and after the signed informed consent, both training modalities were offered. If the patient had impaired balance, according to the Minibestest (MBT) training with NIVR was suggested. Suggested training data for patients with synchronous OTR and asynchronous telerehabilitation were analyzed through NIVR. A formal sample size calculation was not performed; therefore, the type of sampling was non-probabilistic consecutive. The data evaluated in the case of OTR were: Non- Invasive Mechanical Ventilation; Invasive Mechanical Ventilation; Treatment in the prone position; Length of stay in ICU. The following clinical parameters were considered: Heart rate; The oxygen saturation; Sit to Stand test in one minute (1-MSTST); The Short Physical Performance Battery (SPPB); The Post - COVID-19 Functional Status Scale (PCFS) survey; the number of sessions performed and adherence to rehabilitation. In the case of NIVR, the following parameters were evaluated: Non- Invasive Mechanical Ventilation; Invasive Mechanical Ventilation; The length of stay in ICU; Functional Status Score for the Intensive Care Unit (FSSICU) at discharge; Montreal Cognitive Assessment; Minibestest; Functional Gait Assessment; 4-meter walking speed (4MGS); The Post - COVID-19 Functional Status Scale (PCFS) survey. The total training time, the level of difficulty, the performance, the level of adherence to the sessions were identified, and parameters related to the response time achieved against low limb resistance (LLR) and sitting-standing exercises (SST) were evaluated. A descriptive analysis of the data was carried out, the means and deviations or medians and interquartile ranges were obtained for the quantitative variables depending on the distribution of each variable and for the qualitative variables the absolute frequencies with their respective relative frequencies were calculated.

Results: The average age of the 45 patients assigned to OTR was 49.7 years (SD 10.3), while the average age of the 5 patients assigned to NIVR was 62.4 (SD 4.6), in both groups the percentage of male participants exceeded the 70%. Online telerehabilitation (OTR): The median in minutes of training was 150 (IR 30-300), while the median of the days of NIMV and IMV were 7 (IR 5-9) and 6 (4-11) respectively, the correlation between the days of training and heart rate was -0.44 (p value = 0.05). The median of 1-MSTST was 29 (IR 24 – 35). The median values of the PCFS scale in the initial evaluation were 1 (IR 0-3) and in the final evaluation they were 0 (IR 0-0) showing statistically significant differences (p value < 0.001). Finally, adherence to training was 51%. Non- Immersive Virtual Reality (NIVR): The median days of training were 18 (IR 12-40), while the median days of NIMV and IMV were 11 (IR 3-11) and 10 (9-15) respectively. The initial gait speed test (4MGS) reported a median of 0.55 (IR 0.50-0.95) and a final median of 1.20 (IR 1.10-1.60). The initial median MOCA score was 27 (IR 27 -28) and final 28 (IR 28-28). The Minibestest showed an initial median of 20 (IR 20-23) and final 27 (IR 26-28). The level of difficulty of the LLR and the SST presented a median of 57 (IR 50-57) and 20 (IR 18-25) respectively, while the performance showed a median of 90 (IR 45-91). Finally, the functional evaluations of the initial and final gait were 27 (IR 21-27) and 29 (IR 28-30), respectively.

Discussion: The most important finding of this study was that 49-year-old adults with post-acute covid syndrome achieved good results on the 1-MSTST after 5 sessions or 150 minutes of training, which implied no functional limitations at the end of treatment. These results are also appreciated in VR training. According to the evidence, the mean number of 1-MSTST repetitions reported in the literature achieved ranged from 8.1 (patients with stroke) to 50.0 (young men). Therefore, the results obtained in this study are within these ranges. The 4MGS had the best correlation with exercise tests; however, it may be difficult to standardize in a home environment during a virtual assessment. In the case of training with NIVR, changes were observed, which could be associated with a better functional state, according to the PFCS. NIVR would have an advantage over OTR, since it favors the patient's self-efficacy and could accelerate the acquisition of autonomy, directly influencing its functionality. In turn, the quantification of training allowed to identify parameters related precisely to training, such as: training time, level of difficulty, performance, response time and these data can be correlated with clinical data. In contrast, OTR preserves the classic paradigm of care directed by the physiotherapist in face-to-face rehabilitation and the black box of non-training time. A limitation of this study is the size of the sample and the challenge for a future study is to measure the same clinical parameters, before and after treatment, regardless of the therapeutic alternative used. A strength was that the institutional service previously had a measurement and treatment system for cardiovascular and neurological patients, in addition to training with OTR and NIVR, which made it possible to unify criteria and gradually add strategies for more efficient rehabilitation. In conclusion, as that in other studies it seems that the virtual evaluations and treatments responsive and then are a reliable and valid tool to assess the physical capacity in older adults and chronic obstructive pulmonary disease (COPD) patients. Additional to, this study is a first approach to the evaluation and treatment of these patients in these very adverse conditions given the pandemic. It × s hope that the future studies to have a larger sample of patients and a more rigorous systematization of information, which serves as input and support to improve, propose and evaluate a training process.

  Experience of neurorehabilitation in Latin America during COVID-19 Top

Marcos Maldonado-Díaz

Orthotist & Prosthetist, Outpatient Neurorehabilitation Unit, Physical Medicine and Rehabilitation Service of Clinica Alemana, Universidad del Desarrollo, Santiago, Chile E-mail: [email protected]

Economic and social context As of June 28, 2021, more than 1,260,000 people had died from the coronavirus disease (COVID-19) in the countries of Latin America and the Caribbean, in what constitutes the largest health crisis in the recent history of the region. Unequal access to vaccines and health services (both by countries and social groups) and the appearance of new variants of the virus increase uncertainty about the evolution of the pandemic and the consequent opening and recovery of economies. In a global context in which economic, social and environmental asymmetries are exacerbated, the pandemic led to the region's economy experiencing the largest Gross Domestic Product (GDP) contraction since 1900 (6.8%) and registering the worst performance among developing regions. Latin America and the Caribbean is the region with the highest weight of external debt in GDP (56.3%) and with the highest service of external debt in terms of exports of goods and services (59%) (Credit Suisse Research Institute, 2021). These levels of indebtedness reduce fiscal space and jeopardize future growth and recovery. No significant changes have been observed in the institutional framework of development financing to respond to the economic and social impact of the pandemic, and the financing of international financial institutions made available to the international community has been less than that of the global financial crisis.[1] Digital Transformation of the Health Sector Below are some data associated with the universalization of access to digital technologies to face the impacts of COVID-19. Latin America and the Caribbean managed to connect 2/3 of its population to the Internet. Mobile broadband predominates (67.5%). The largest gaps are between quintiles and between urban and rural areas. 40 million homes are not connected. Digital transformation is irreversible. Access to high-speed broadband is essential for effective participation in the digital age. Telemedicine improves access to health services, reduces costs and increases the capacity to prevent diseases during quarantines. Decongests health centers and hospitals, prevents infections and flattens epidemiological curves. It requires legal frameworks for online health services, the digitization of medical information, interoperability, and the protection of privacy and security.[2] The Information Systems for Health (IS4H) Conference, From the Evolution of Information Systems for Health to the Digital Transformation of the Health Sector, aimed to create a dialogue of reflection with the countries of the Region of the Americas on their experiences regarding their information systems and digital health during the last four years, especially during the COVID-19 pandemic. Discussions at the preparatory sessions focused on the strategic goals of the IS4H Plan of Action. The approximately 150 participants recognized the importance or working together with a common goal and under the eight principles presented by the Pan American Health Organization (PAHO) for the digital transformation of the health sector: 1- Achieve universal connectivity in the health sector. 2- Co-create digital public health goods for a more equitable world. 3- Accelerate progress toward inclusive digital health. 4- Implement open, sustainable, interoperable digital information and health systems. 5- Mainstream human rights across all areas of digital transformation in health. 6- Participate in global cooperation on artificial intelligence and any emerging technology. 7- Establish mechanisms for the confidentiality and security of information in the digital public health setting. 8- Design a renewed public health architecture for the age of digital interdependence.[3] Impact of the pandemic on physiotherapy services In 2020, World Physiotherapy sent its member organizations a survey that included questions about how the pandemic had impacted the practice of physical therapy and how COVID-19 had affected the functioning of member organizations. Participation of Latin America and the Caribbean: 86%. 12 out of 14 member organizations. The total number of participating therapists was 256,490. Most of the member organizations reported that the practice of physiotherapy had been interrupted during the pandemic in their territory, for two or three months, mainly between March and May 2020. The percentage of territories where physiotherapy services were discontinued: 100%; private practice: 100%; public assistance: 73%; primary care: 100%; geriatric residences: 77% Physical therapists played an essential role in treating patients in all phases of COVID-19. The investment and recognition of tele-physiotherapy services could be an effective way to face the challenges and needs of the population to access the services of physiotherapists. Patients with chronic conditions could be particularly vulnerable to interruption of physical therapy services and therefore strategies must be put in place to deal with this situation. New strategies will need to be developed to address problems related to people affected by persistent Covid in need of rehabilitation. Physiotherapists will play a key role in this process.[4] Disability context The population with disabilities in Latin America and the Caribbean is highly vulnerable to the social and economic impacts of the COVID-19 pandemic due to pre-existing structural challenges such as their poverty situation and the deep inequalities that affect them in all areas. The effects of this pandemic could generate significant setbacks in the timid advances in the situation of social inclusion and effective access to rights for people with disabilities. The scant information available at the regional level in the current context makes it impossible to estimate with reliable data the impact of the pandemic on the population with disabilities or how many people with disabilities have access to the mitigation and control measures that are being implemented in the areas of health, education, social protection and work. Some of the fundamental questions remain open: how many students with disabilities cannot continue with their studies How many families have seen the care and rehabilitation strategies required by their members with disabilities interrupted How many girls and women with disabilities require protection in order not to be victims of gender or domestic violence How many people with disabilities have lost their jobs To assess the situation of the population with disabilities, this information is crucial; However, it is worrying to see that in very few cases it is collected or analyzed. In the current context, and especially in the immediate future, it is essential to strengthen the collection and systematization of data on disability in the instruments of the national statistical systems; in particular, in administrative sources.[5] Recommendations Guidelines It was drafted recommendations made by consensus of a group of experts at the international level for the approach of the COVID-19 patient in the pediatric, adult population, and vulnerable groups with special attention to spinal cord injury, within an integrative vision.[6] A group of experts in neurorehabilitation in Chile, suggested that post-COVID people who enter outpatient rehabilitation and are referred to neuro- physical therapy must present some of the following conditions: 1. “Post-COVID-19 Functional Status (PCFS) Scale” o Moderate and severe functional impairment: Grade 3-4. 2. Person with the presence of a neurological diagnosis during hospitalization for COVID, including: ischemic stroke, encephalopathies, encephalitis, Guillain Barré syndrome, polyneuropathies and severe critical patients' myopathies. 3. Person with an inability to walk, who requires the help of one or more people or the continuous and/or intermittent support of another person to maintain balance and/or coordination. 4. Person with total or severe dependence according to the Barthel Index (score < 60). 5. Person with moderate or severe balance alteration according to Berg's balance scale (Score < 40). 6. Person with a score on the SPPB scale < 8. 7. Person with pre-existence of neurological condition with previous affectation of their level of functionality. 8. Post-COVID-19 Functional (PCFS Scale), it is recommended to specifically assess the following neurological impairments and activity limitations. 9. Basic activities of daily living (ABVD): Barthel index. 10. User specific functionality: Patient Specific Functional scale (PSFS). 11. Strength: Medical Research Council (MRC). 12. Sensitivity: Nottingham Sensory Assessment (NSA) 13. Static and dynamic balance: Mini Best Test, Activities-Specific Balance Confidence Scale. (ABC), Berg balance scale. 14. March: Functional Ambulation Category (FAC). 15. Technical aids: Tinetti scale.


  1. Special Report COVID-19. CEPAL; July 08, 2021.
  2. COVID-19 Observatory in Latin America and the Caribbean. Economic and Social Impact. ECLAC; 2021.
  3. From the Evolution of Information Systems for Health to the Digital Transformation of the Health Sector. IS4H Conference Report. Department of Evidence and Intelligence for Action in Health (EIH). Pan American Health Organization (PAHO); 2021.
  4. Impact of the Pandemic on Physiotherapy Services. World Physiotherapy. Census; 2020.
  5. Meresman, et al. COVID-19 and People with Disabilities in Latin America. ECLAC; 2020.
  6. Hernandez S, et al. Manual of recommendations for comprehensive rehabilitation care for patients with COVID-19. Ibero-American Consensus on Rehabilitation. Latin American Committee for the Management of Scientific Information in Rehabilitation; June 23, 2020.
  7. Interdisciplinary Consensus on Rehabilitation for Adults Post COVID-19. Recommendations for Clinical Practice. Work Developed between Scientific Societies and Professional Schools in the Rehabilitation Area. Chile; August, 2020.


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]

  [Table 1], [Table 2]


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