3.

04 Neurorehabilitation NEUROLOGY
Arnel V. Malaya, M.D., FPARM LE 3
01 December 2020 (Tue) TRANS 4

OUTLINE Model: CEREBRAL STROKE

C. Pharmacological Agents ● Leading cause of disability worldwide

I. Neurorehabilitation
II. Neuroplasticity
III. Basic Principles of
Neuroplasticity
IV. Why Neuroplasticity is
Possible
V. Mechanisms of
Neuroplasticity
VI. Types of Recovery after Brain
Injury
VII. Non-invasive Assessment of
Neuroplasticity
VIII. Goal of Rehabilitation
and Strategies
IX. Management
A. Therapeutic Exercises
to Induce Movement
and Mobility
B. Treatment of Post-Stroke
Depression
Important Recording
☜ ☊
1
to Enhance Plasticity 7 ○ 15M stroke cases/year worldwide
1
D. Use of Technology to ○ 1/3 or 5M recover with good function
Enhance Activity and ○ 1/3 or 5M die
1
Sensory Stimulation 7 ○ 1/3 or 5M permanently disabled
E. Other Modes of ● Outcomes:
2
Management 10 ○ Overall mortality is declining
F. Future Modalities ○ Long-term survival post-stroke is improving
2
of Treatment 11
III. BASIC PRINCIPLES OF NEUROPLASTICITY
3 G. Management of Early
Phase 11 ● Neuroplasticity or brain plasticity is the basis for
X. Important Points 11 neurorehabilitation
3
XI. Conclusions 11 ○ Applicable to both intact and damaged brain
4 XII. Challenges of
Principle #1: “USE IT OR LOSE IT”
5 Neurorehabilitation 12
XIII. References 12 ● Neural circuits not used actively in a task performance for
extended periods of time begin to degrade
○ Ex: In patients fed by NGT, the swallowing mechanism, which is
5 composed of the oropharyngeal muscles, may weaken or can
Review Questions 12
Summary 14 even go into atrophy due to lack of use over time.
7 ■ It does not only weaken in terms of muscle strength, the
neural connections become weak also. Therefore, it may
LEGEND take some time (many repeated trials) to reestablish the
Book/Article Previous Trans circuit and restore the swallowing ability of the patient after
the entity is removed. ☊
(Author (ed), pp.) (Year & Section)

● Brain needs to use activity/experience to initiate new synaptic

Lecture Objectives
At the end of the lecture, the student should be able to:
1. Explain the concepts of neuroplasticity and neurorehabilitation.
2. Discuss the basic principles governing neuroplasticity.
3. Describe the current techniques of documenting neuroplasticity.
4. Explain the effects of neurorehabilitation on disabling
syndromes, especially in stroke.
5. Demonstrate the present neuro-rehabilitative techniques in
stroke.
6. Assess some new and promising techniques and concepts in
the rehabilitation of stroke.
I. NEUROREHABILITATION
connections between neurons
○ The more a part is used, the bigger its area of representation in
the brain that correlates with improved function
● “Use-dependent plasticity” / “Experience-dependent plasticity”
Principle #2: “USE IT and IMPROVE IT”
● Training that drives a specific brain function can lead to an
enhancement of that function.
● “Neurons that fire together, wire together.”
○ Ex: CIMT (Constraint-Induced Movement Therapy)
■ The non-affected arm is restrained to compel the patient to
use the affected limb as much as possible and improve its
function.

● The 3rd phase of health care Principle #3: “SPECIFICITY”

■ Prevention → Intervention → Rehabilitation (to bring the the
patient back to as near normal as possible ☊)
● A process whereby patients who suffer from impairment following
neurologic diseases, regain their former abilities, or if full recovery
is not possible, achieve their optimal physical, mental, social and
vocational capacity.
● Popovic and Sinkjaer (2003) – “comprises methods and
technology for maximizing the efficiency of preserved
neuromuscular structures in humans with motor disability”.
● Wikipedia – a complex medical process which aims to aid
recovery from a nervous system injury, and to minimize and/or
compensate for any functional alterations resulting from it.
II. NEUROPLASTICITY / BRAIN PLASTICITY
● Theory first proposed by psychologist William James (1890)
○ The amazing capability of the CNS (or the brain) to reorganize
by forming new neural connections throughout life
● Allows the neurons in the CNS to compensate for injury and
disease, and/or adjust their activities in response to new situations
or to changes in the environment
● Nature of the training experience dictates the nature of the
plasticity
○ Importance of tailoring an activity or exercise to produce a
result in specific circuitry
○ Ex: Training in swallowing after a stroke may not automatically
generalize to training in voice production or speech.
Principle #4: “REPETITION MATTERS”
● Induction of plasticity requires sufficient repetition to induce lasting
neural changes.
○ May be needed to obtain a level of improvement and brain
reorganization sufficient for the patient to continue to use the
affected function outside of therapy
● Critical in rehabilitation
Principle #5: “INTENSITY MATTERS”
● Induction of plasticity requires sufficient intensity.
● The more intensive the therapy program, the more likely a
person is to achieve results and the more likely these changes are
to be maintained over time.

TRANS (12) Ruiz, Salcedo, Samonte, San Pedro (2022C) CORE Salubayba, Salvacion (2022C)
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○ Ex: Animals trained on a skilled reaching task to perform 400

reaches/day had greater increases in number of synapses in
the motor cortex vs. 60 reaches/day.
● How often and many sessions, to get better?
● Caveat: possible overuse, especially in early phase post-injury
○ Possibly due to exaggeration of excitotoxicity in the vulnerable
tissues surrounding the primary injury (Humm, et al, 1999)
Principle #6: “TIMING MATTERS”
● Different forms of plasticity occur at different times during
recovery.
○ Natural tendency of the body to repair after a brain injury.
○ Start treatment ASAP before maladaptive behaviors set in.
● Ex: Rehabilitation started 30 days after stroke are found to be less
effective functionally and neurologically vs. treatment started 5
days post-stroke.
Principle #7: “SALIENCE MATTERS”
● The training experience must be sufficiently salient or important to
induce plasticity. Figure 1. Diffusion tensor Imaging of nerve tracts
○ If training or information can be made more meaningful,
relevant, and enjoyable to the patient, they can more easily NEED-TO-KNOW:
remember skills or pieces of information that are important to ● Neurorehabilitation: process where patients affected by
them neurological disease regain their former abilities, or if full
● Sufficient attention and motivation is needed. recovery is not possible, achieve their optimal physical,
○ Important for aphasia or motor speech disorders. mental, social and vocational capacity
○ Ex: 1) basic ADL / Instrumental ADL, 2) use of Wii Fit ● Neuroplasticity: CNS capability to reorganize by forming new
neural connections throughout life
Principle #8: “AGE MATTERS”
● Basic principles of neuroplasticity:
● Training-induced plasticity occurs more readily in younger brains. 1. Use It or Lose It
○ CNS is especially plastic during childhood and adolescent years 2. Use It and Improve It
● Synaptic stabilization, synaptogenesis and cortical map 3. Specificity
reorganization are all reduced in aging 4. Repetition Matters
○ But still possible in the aged brain 5. Intensity Matters
● “Plasticity is probably the mechanism by which the brain 6. Timing Matters
compensates for aging” 7. Salience Matters
Principle #9: “TRANSFERENCE OR GENERALIZATION” 8. Age Matters
9. Transference or Generalization
● Plasticity in response to one training experience can enhance
10. Interference
acquisition of similar behaviors.
○ Training should be directed on how a particular skill or activity
can be generalized or transferred to real-world activities, CONCEPT CHECKPOINT:
resulting in increased independence in the home environment. 1. What is the CNS capability to reorganize by forming new neural
● Training on a fine-digit movement task induces an increase in connections throughout life?
corticospinal excitability and expansion of hand muscle 2. Name three basic principles of neuroplasticity.
representation in the primary motor cortex
ANSWERS:
○ Ex: Improved prehension patterns of the hand → independent 1. Neuroplasticity
hand feeding or improved sit-to-stand ability → start of walking 2. See above Need-To-Know list
ability
V. MECHANISMS OF NEUROPLASTICITY
Principle #10: “INTERFERENCE”
● Plasticity in response to one training experience can impede A. Angiogenesis
acquisition of similar behaviors. ● Formation of new blood vessels
○ Delayed treatment in post-stroke patients → compensatory
behaviors for skill deficits
■ May take some time to “unlearn” these previously acquired
behaviors or movements
● After unilateral brain damage, reliance on the less-affected body
side may limit individuals in behaviors that improve function of the
impaired side :
● Brain plasticity that results in bad habits can interfere with learning
good habits.
IV. WHY NEUROPLASTICITY IS POSSIBLE
● The existence of significant diffuse and redundant connectivity
within the CNS
● The ability of new circuits to form through remapping

Figure 2. Sprouting vs. Intussusceptive angiogenesis

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● Due to VEGF (Vascular Endothelial Growth Factor)
● When there is an infarction, new blood vessels will try to form to
perfuse the infarcted area
● Especially in the penumbral area, you can have the sprouting type
of angiogenesis or intussusceptive type of angiogenesis.
B. Neurogenesis
● Axonal sprouting
● Mainly seen during brain development in infants and adolescents
and lately proven in the adult brain as well. That is what we mean
by “Neuroplasticity still being possible in the aging brain”.
● Very common and active in lateral ventricles and hippocampus
Figure 3. Axonal sprouting
C. Synaptogenesis
● Formation and fitting of synapse or group of synapses into a neural
circuit
○ Neural circuits are formed throughout life that become active
and stable. This enables activities to be automatic.
● Unmasking of latent synapses
○ Synapses(circuits) that are not used maximally shifts to assume
or accommodate the needed action.
○
Figure 4. Synaptogenesis. (A) Pre and postsynaptic neuro ; (B) Addition phase
wherein new synapses are formed; (C) Remodeling phase wherein more branches
form, connect, and elongate
D. Regeneration
● From neural stem cells in the ventricular zones, subventricular
regions, and choroid plexus, migrating to the ipsilateral, peri-infarct
area
E. Chemical Mediators (Neurotrophins)
● Nerve Growth Factor (NGF) (1950s)
○ The founding member of neurotrophins
○ A neurotrophic factor and neuropeptide primarily involved in the
regulation of growth, maintenance, proliferation, and survival of
certain target neurons.(2021)
● Brain-Derived Neurotrophic Factor (BDNF) (1980s)
○ Promotes survival of neurons by playing a role in the growth,
maturation, and maintenance of these cells.(2021)
○ BDNF is neurotrophic and neuroprotective
○ Most abundant growth factor in the brain.
○ Animal studies suggest the BDNF is a key mediator in synaptic
efficacy, neuronal connectivity and use-dependent plasticity.
● Neurotrophin-3 (NT-3) (1990)
○ Growth and differentiation of new neurons and synapses
○ Support survival and differentiation of existing neurons
● Neurotrophin-4 (NT-4) (1991)
○ Similar to NT-3
● Neurotrophin-5 (NT-5) (1992)
● Neurotrophin-6 (NT-6) (1996)
○ found in Teleost fishes (tuna, salmon, piranha, trout)
VI. TYPES OF RECOVERY AFTER BRAIN INJURY
1. Spontaneous Reorganization
○ Reflects the recovery of neurotransmission in spared tissues
near and remote from the site of injury.
○ Limited by time: (EN: These are the GOLDEN PERIOD of
recovery) (2021)
■ Stroke: 3 months
■ Traumatic Brain Injury (TBI): 6 months
○ Usually happens in the first 3 months in an infarct type of
stroke. In a traumatic brain injury, you can wait for about 6
months.(2021)
2. Training-induced Recovery
○ Not limited by time
○ Recovery can happen beyond the golden period. Not
dependent on time.(2021)
○ Dependent on individual experience and adaptation and/or
rehabilitation techniques a patient undergoes.
■ It helps that you have the right kind of rehab program and
activities to induce good functional recovery in chronic
cases.(2021)
CONCEPT CHECKPOINT:
1. Spontaneous reorganization for stroke patients occurs within
which limited time frame?
2. What is responsible for angiogenesis in the brain?
ANSWERS:
1. 3 months
2. VEGF
VII. NON-INVASIVE ASSESSMENT OF NEUROPLASTICITY
1. Functional MRI Scan (fMRI)
● Most important one (2021)
● Have opened windows to study the dynamics of brain
reorganization after injury
○ While the patient is moving, you can actually see the brain
activity.(2021)
● fMRI and Motor Recovery
○ Hand Gripping Data
■ Shows activity in the brain during repetitive gripping with the
right hand. Each brain represents the activation pattern at
different time points over the first six weeks after stroke for
one patient.
■ Recovery of function is associated with diminishing brain
activation, due to increasingly efficient neural circuitry.
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■ This is very similar to what is seen during learning of a new
complex motor task in the undamaged human brain.
Figure 5. Recovery of Grip Strength. When the patient was doing gripping
movements, 2 weeks post-stroke, both hemispheres showed activities. After 6
weeks, only the left hemisphere showed activities meaning it became more efficient.
Another lesson is that both hemispheres can actually function and help out in the
recovery process. If you move your right hand, it’s not only the contralateral side
working, but even the ipsilateral side can also become active. But overtime, with
practice and as it becomes more efficient, activity becomes more confined to the
contralateral side.(2021)
2. Transcranial Magnetic Stimulation (TMS) Mapping
● Uses electromagnetic waves from a copper coil to determine the
electrical excitability of brain tissues and to be able to pinpoint
exactly the tissues or which part of the brain that needs to be
stimulated
● Now being used as both diagnostic and therapeutic (2021)
● Not yet available here (2021)
● Determines the electrical excitability of brain tissue by measuring
the muscular response to stimulation.(2021)
● Instead of introducing dyes to visualize, this is an extracranial way,
assessing brain activity through muscular response to stimulation.
This is a very new modality.(2021)
Figure 6. TMS mapping
3. Functional Imaging (PET Scan)
● Measures blood flow, oxygen and sugar metabolism
● Helps reveal how your tissues and organs are functioning by using
a radioactive drug (tracer) to show this activity.
● This scan can sometimes detect disease before it shows up on
other imaging tests.(2021)
● When coupled with (11-C)-PK 11195, a benzodiazepine receptor
ligand that binds to activated microglia in the brain, is a marker for
neuroinflammation
Figure 7. Inflammation surrounding stroke seen in PET scan with (11-C)-PK 11195
4. Single Photon Emission Computed Tomography (SPECT)
● Detects neurotransmitters
○ Most common is glutamate (2021)
○ Also detects self-defect neurotransmitters (2021)
● Measures neurophysiological metabolic processes in the CNS
5. Diffusion Tensor Imaging (DTI)
● Tractograms
● Visualizes the white matter fiber tracts of the CNS and the
quantification of fiber tract integrity
● Not used for predicting the possibility of recovery (2021)
● A 3D modeling technique used to visually represent nerve tracts
using data collected by diffusion MRI. It uses special techniques of
magnetic resonance imaging (MRI) and computer-based diffusion
tensor imaging. The results are presented in two- and
three-dimensional images called tractograms.(2021)
6. Regional Cerebral Blood Flow (rCBF) Studies
● Measures local neuronal activity
● Using PET Scan with H2(15)O (oxygen-15-labeled water), can
detect changes in rCBF in response to motor tasks such as limb
movements.
7. Near Infrared Spectroscopy (NIRS)
● Senses the variation in intracranial oxy and deoxy hemoglobin (2021)
● Functional near infrared spectroscopy (fNIRS) is a non-invasive
optical imaging technique that uses low levels of light to measure
blood flow changes in the brain associated with brain activity, such
as performance of a task.
8. High-Density Electroencephalogram (EEG)
● Measures electrical signature of cortical pyramidal neuron
excitation.
● Uses a cap with large number of scalp electrodes than ordinary
EEG exam
9. Magnetoencephalography (MEG)
● Functional neuroimaging technique for mapping brain activity by
recording magnetic fields produced by electrical currents,
occurring naturally in the brain, using very sensitive
magnetometers.
10. SCAPE (Swept Confocally-Aligned Planar Excitation)
Microscopy
● Enables scientists to see brain structure at a microscopic level
● A 3-dimensional observation of individual neurons in the brain
11. Regional Metabolic Rate of Glucose(rCMRglc), by PET and
SPECT
● Also another way of non-invasive investigation of brain function by
studying the cells’ glucose metabolism
CONCEPT CHECKPOINT:
1. What is a sign of recovery of brain function seen in fMRI?
2. What technique detects neurotransmitters?
3. What does near infrared spectroscopy sense?
ANSWERS:.
1. Recovery of function is associated with diminishing brain activation, due to
increasingly efficient neural circuitry
2. Single Photon Emission Computed Tomography (SPECT)
3. variation in intracranial oxy and deoxy hemoglobin
VIII. GOAL OF REHABILITATION AND STRATEGIES
● Objectives for stroke rehab
○ Achieve a maximum level of functional independence
○ Minimize disability
○ Successfully reintegrate back into home, family and community
○ Reestablish a meaningful and gratifying life
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● Strategies to achieve the goals

○ Therapy to reduce impairments (loss of anatomical and
physiological functions ☊)
○ Functional training to compensate for residual impairments
○ Use of assistive devices, e.g., braces, wheelchair to substitute
for lost function.
○ Resolution of psychosocial issues that occurs during integration
of the patient back to home and community
IX. MANAGEMENT / NEUROREHABILITATION TECHNIQUES

A. THERAPEUTIC EXERCISES TO INDUCE MOVEMENT AND

MOBILITY

1. Constraint Induced Movement Therapy (CIMT)

Figure 9. Mirror therapy. You have here the right hand (the normal side) and the
● Principle of FORCED USE to avoid the learned non-use of the affected side (inside the mirror). When the patient views the mirror and sees the
paretic side for stroke patients and promote cortical reorganization. reflection of the moving arm, she is basically tricking the brain that it was actually
● Mainly for training upper extremity the left hand that is moving. ☊
● Needs minimal voluntary movement
● Originally developed by: Dr. Edward Taub, a behavioral
neuroscientist
● “Demonstrated through transcranial magnetic stimulation (TMS)
mapping, that constraint-induced rehabilitation augmented the
motor cortical areas representing hand movement for as long as 6
months.” (Liepert, et al. 2003.)
○ Liepert - one of the earliest neuroscientists that has been able
to confirm the effect of CIMT in TMS mapping.
● Effects: cortical reorganization, dendrite branching, synaptic
strength and redundancy learned (Multisynaptic connections).

Figure 10. Brain scan in Mirror therapy

Figure 8. CIMT. The less affected arm/the normal arm is actually on a

sling. We are trying to force the patient to use the affected side to
prevent a learned non-use principle. ☊

2. Mirror Therapy
● Principle: that movement of the affected limb can be
stimulated via visual cues originating from the opposite side
of the body.
● Form of motor imagery in which a mirror is used to convey visual
stimuli to the brain through observation of one’s unaffected body
part as it carries out a set of movements.
Figure 11. fMRI of a Patient Undergoing Mirror Therapy.
● Use of the stronger UE and LE to “trick our brain” into thinking that
the weaker arm or leg is moving 3. Sensory Stimulation
● Basis: The IPSILATERAL and CONTRALATERAL hemisphere ● Environmental stimulation (opening up the windows, the patient
can contribute to motor control.
should be able to see the outside world if it is possible ☊)
● Evidence of therapy : fMRI
● Verbal and Non-verbal stimulation
○ In a pilot study, fMRI demonstrated that brain areas, that are
● Electrical Stimulation
involved in sensory-motor-learning (mirror-neurons base of the
○ Functional electrical stimulation is a variation of electrical
cortex), are activated by the visual illusion from mirror therapy.
stimulation where the patient has some degree of voluntary
○ In just visual observation of the affected side you can also
control.(2021)
activate the contralateral side, and later on, can develop into
● Stroking and massaging
control to the affected side.

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● Hilot - Stimulatory technique but has not been proven, last resort ○ In recent studies, no significant difference have been found in
(2021)
functional outcomes of stroke patients given Bobath, PNF,
● Treat post-stroke depression but do not use drugs that induce Brunnstrom and/or strengthening treatments
drowsiness (2021) ■ Effects are not consistent but are still popular and basic
therapeutic techniques that rehab professions have been
using, in addition to the CIMT and mirror therapy ☊

Figure 12. Verbal stimulation. Even if the patient is actually obtunded or

comatose, the caregiver tries to speak to the patient in a normal way as possible.
This is part of the stimulation. ☊

4. Neurodevelopmental Techniques (NDTs) by Bobath Figure 14. Proprioceptive Neuromuscular Approach in Rehab

● Emphasize exercises that tend to normalize muscle tone and
prevent excessive spasticity through special reflex-inhibiting
postures and movements
● For beginning or early spastic stage
● For late and severely spastic muscles - Slow, sustained
stretching is applicable
● Vibration of antagonist muscles may reduce tone through
reciprocal inhibition. (So, if the biceps muscles are spastic, you do
the vibration of the triceps muscles.☊)
7. Sensorimotor approach
● Rodd’s approach
○ Involves superficial cutaneous stimulation using stroking,
brushing, tapping and icing or vibration to evoke voluntary
muscle activation
■ For example, the biceps. As the therapist tries to stimulate
biceps contraction, what he’s doing is actually stroking the
skin over the biceps. He can also do vibrations in the hope
that it will evoke voluntary contraction of the biceps. ☊
8. Conventional Physical Therapy
● ROM exercises
● Stretching and strengthening
● Attempting to retrain weak muscles through muscle reeducation
● Developing gross trunk control and training in pre-gait activities
such as posture, balance and weight transfer to the hemiparetic
leg.
● Once with strong synergies and spasticity, many will walk with a
cane and ankle-foot orthosis (AFO)

Figure 13. Neurodevelopmental technique - Stretching

5. Movement Therapy: Brunnstrom's Approach

● Emphasize synergistic patterns of movement that develop
during recovery from hemiplegia
○ Synergy - a whole series of muscles are recruited when just a
few are needed
○ Synergistic patterns are gross movements that you will see in
stroke patients who are recovering ☊
● Encourage the development of flexor and extensor synergies Figure 15. Conventional Physical Therapy. ROM exercise of the lower
during early recovery, hoping that synergistic activation of the extremities
muscle would, with training, transition into voluntary activation
○ Why flexor and extensor synergies? Because if you realize,
most of the movements of the extremities, even the trunk,
involve a lot of flexing and extending of the joint, so this is the
way they approach to stimulate the recovery and achieve
voluntary integration of muscles. ☊
○

6. Proprioceptive Neuromuscular Facilitation (PNF)

● Kabat and Knott’s approach
○ Relies on quick stretching and manual resistance of muscle
activation of the limbs in a functional direction, which are often
spiral and diagonal Figure 16. Conventional Physical Therapy. The patient is being trained by a
■ If you realize, when you try to eat with upper extremities, the PT to do a shifting of the weight bearing to the paretic leg to develop a good
movement is not planar, but is actually a simultaneous balance and posture as a prerequisite before he starts to walk. You cannot
make a shortcut of going directly to walking without the patient developing a
diagonal or oblique or spiral movements when you try to
good standing balance and tolerance, and weight transfer.☊
bring the food in your mouth.

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Figure 17 .Ankle- foot orthosis
B. TREATMENT OF POST-STROKE DEPRESSION
● Treat post-stroke depression and not use drugs that induce
drowsiness
○ Diazepam is not advisable because it will cause drowsiness in
some patients
● Reduction of inhibition enhances plasticity
● Positive reinforcement of the progress in rehab
○ Document improvement, no matter how small it is, so that
patients will be more cooperative.
● Individual psychotherapy
● Ex. Desipramine and or Selective serotonin uptake inhibitors
(SSRI)
○ Fluoxetine (PROZAC)
C. PHARMACOLOGICAL AGENTS TO ENHANCE PLASTICITY
3. Neuroprotective Agents
● Glibencamide (DIABETA)
○ Selective sulfonylurea receptor I Inhibitor
○ Specifically targets damage from secondary neuroinflammation
■ Decreases neuroinflammation ☊
● D-cycloserine (SEROMYCIN)
○ Partial agonist of the N-methyl-D-aspartate (NMDA) receptor for
glutamate
○ Can potentiate learning and neuroplasticity in animal models
○ Anti - TB drug (2021)
4. Neurotronics and Nootropics
● Other drugs that claims to have some effect on neuroplasticity or
can induce brain rewiring or brain reorganization ☊
● These medications are commonly prescribed although they are not
essentially indicated for inducing neuroplasticity (2021)
● Citicholine
○ Promotes improved circulation of affected areas in the CNS
(brain ☊)
■ Doing so may also improve neuroplasticity ☊
● Piracetam
○ Cognitive enhancers
■ Executive functions, memory, creativity, and motivation.
○ Generally given to healthy subjects, but are also tried in some
stroke patients ☊
○ Popular among students(2021)
D. USE OF TECHNOLOGY TO ENHANCE ACTIVITY AND
SENSORY STIMULATION
1. Functional Electrical Stimulation (FES)

1. Cerebrolysin
● For ischemic stroke
● To reduce infarct site and promote repair and improve functional
outcome
● IM or IV
○ Porcine-brain derived aqueous protein solutions which can
penetrate the blood-brain-barrier
● It can induce severe allergic reactions (2021)
● Derived from a pig brain

Figure 18. Cerebrolysin

2. Neuroaid II (MLC 601/ MLC 901)
● Traditional Chinese herbs
● To improve neurological recovery after stroke
○ In a 2013 systematic review of patients in a multi-center trial
showed “some evidence in improving further functional
independence and motor recovery and is safe and non-acute
stable stroke
○ Another study among Asians showed that “it is no better than a
placebo”
● Route: oral (2021)
● Can be classified as a supplement(2021)
● Because of the dearth of drugs to improve spasticity, we are still
using these two (Cerebrolysin and Neuroaid II) especially for acute
stroke patients. ☊
Figure 19. FES treatment. Stimulates the tibialis anterior muscle that causes
dorsiflexion of the foot, and therefore prevents the patient from scraping the floor
● Mainly for the lower leg
● Kessler Rehab found it to be beneficial to improve foot drop in 4
weeks
● Applicable only to those with residual voluntary muscles
contraction; not for flaccid patients
● How does FES work? (2021)
○ For foot drop, the device is usually worn in a cuff below the
○ knee. This is where the electrodes can stimulate the nerve that
goes to the muscle that would normally lift the front of your
foot. At the right moment in your gait, when your foot is about to
lift up to be swung forwards, the FES device stimulates the
nerve.and lifts the foot

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○ The stimulation stops when the foot hits the ground again. It ● It functions as a biofeedback device where a surface
may take some time to adjust the timing specifically for you and electromyography (sEMG) sensor utilizes a patient’s own muscle
your gait. Some FES devices have a sensor that is worn in the signals to activate their desire to move their hand. These signals
heel area, to help with the timing, but in modern devices that is are processed and simplified and can be seen through visual
optional. This means that the FES device can be worn with bare feedback that requires the patient to be actively engaged through a
feet or sandals. therapy session. (2021)
○ EN: Explanation behind FES: by introducing electrical
stimulation you send “impulses” to your nerves which
propagates action potential. Electrical stimulation can be used
for both sensory and motor nerve stimulation. FES is a
configuration of electrical stimulation wherein you use electrical
stimulation to increase motor recruitment during FUNCTIONAL
movements, therefore creating a stronger and more sustained
contraction of a particular muscle or muscle group.
○ EN: Most common use of FES is for (+) foot drop patients.
Meaning the patient has a paretic/plegic tibialis anterior (main
dorsiflexor) that’s why the “foot drops” since there is nothing
pulling it up.
2. EMG Biofeedback Figure 21. Hand of Hope rehabilitation
● Supplements neuromuscular re-education
4. DARPA’S “Luke Skywalker Arm”
● Uses auditory and visual display as feedback of ongoing
muscle activity. ● DARPA - Defense advanced Research Projects agency of the US
● Have shown some benefits in control of motor function or muscle Department of Defense
strength of the upper extremities. ● Active moments through robotics
● Use of external electrode ● Commercially available
● Good for partial recovery; promotes functioning ● Powered shoulder
● A method of retraining muscles by creating new feedback systems ● Movements: Shoulder abduction/adduction, humeral rotation,
as a result of the conversion of myoelectrical signals in the elbow flexion/extension.
muscle into visual and auditory signals. ● Multifunctional hand and fingers
● EMG uses surface electrodes to detect a change in skeletal ● This is actually being tried for amputees of their servicemen and
muscle activity, which is then fed back to the user usually by visual probably among soldiers in the future ☊
and auditory signal. (2021)
● EMG biofeedback can be used to either to increase activity in a
weak or paretic muscle or it can be used to facilitate a reduction in
tone is a spastic one.(2021)
● EMG biofeedback has been shown to be useful in both
musculoskeletal and neurosurgical rehabilitation.

Figure 22. DARPA Luke Skywalker Arm

5. BrainCo’s “mind-control headband”

● Hacks into brain signals to control a prosthetic hand, by just
focusing on it.
○ ○ Can be used instead of usual electrodes used in EEG
Figure 20. EMG Biofeedback. (R) There is an electrode attached to the ● Can also be used for improving attention spans, detecting disease,
muscle, in this case, the brachioradialis that causes wrist dorsiflexion, and or controlling smart home appliances
this is actually attached to a monitor. ☊ ● “Neurofeedback” mechanism
3. “Hand of Hope” Robotics ● Developed by Harvard and MIT scientists
● Cost: <$150
● Induction of passive and active movements
○ Through an electrode attached to the muscles of the forearm,
and causes movement in the fingers through the orthotic
devices ☊
● No improvement in upper limb function was evident in
robot-assisted training vs usual care, according to a study by
Rodgers, et al.
● Controls small motor muscles in the forearms.
● Hand of Hope (HOH) therapy device used for neuromuscular
rehabilitation of the hand and forearm that may help patients
regain mobility through motor functioning.(2021)

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Figure 23. BrainCo Mind Control Headband
6. Virtual Reality (VR)
● VR is defined as an approach to a user-computer interface that
involves real time simulation of an environment, scenario or
activity that allows for user interaction via multiple sensory
channels.
● Advantages:
○ (+) Visual and auditory feedback from TV monitor
○ Engaging, entertaining and fun activities
○ Improve the monotonous frustrating experience of rehab
● This is used in rehabilitating patients with amputations ☊
● Example: Wii
Figure 24. WiiSports being used for rehabilitation
7. Treadmill Training with body weight supported by a Harness
● Found to be superior to conventional therapy techniques.
● Patients who are unable to walk or stand by themselves are
suspended on a harness and try to walk over a treadmill; the
therapist is the one pulling the leg. (EN: PASSIVE AMBULATION)
● More affordable than robotics
● Problem: labor intensive
○ Refer to Figure 25: Presence of about 3 physical therapists who
try to move both lower extremities to simulate a normal gait
pattern, another one is controlling the posture of the patient.
Figure 25. Treadmill training supported by a harness
8. Treadmill Training with body weight supported by a harness
with robotics (LOKOMAT system) for paraplegics
● Instead of the therapist controlling the leg, they made use of
robotics in the lower extremities so that the patient could walk as
normal as possible over a treadmill.
● This is an advanced model of the previous on (Treadmill Training
with body weight supported by a harness) ☊
● Not available in the Philippines due to its expensive cost: ~50m
PHP
Figure 26. LOKOMAT system: treadmill, harness, and robotics
9. Exoskeleton Robotic Device for Hemiplegics
● A cutting-edge technology
● External prosthesis
● Wearable exoskeleton robotic device powered by small motors in
the joints from a powerpack in the back.
○ So that the patient can actually walk normally
● Possible future use: In the US, they are trying to see if they can
make use of this for soldiers. You’re having to have super soldiers
later on who can lift heavy objects. ☊
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Figure 27. Exoskeleton device for hemiplegics

● Ekso®: Exoskeleton Robotic Device (2021)
○ Another brand, aside from Rewalk

Figure 29. Brain-computer interface or Closed Loop Brain Stimulation

New Mode of Management: rTMS (Repetitive Transcranial

Magnetic Stimulation
● Non-invasive, deep brain stimulation for the motor cortex to
enhance motor recovery coupled with rehabilitative training
improves motor function.
● Uses electromagnetic waves to enhance motor recovery.
● Principle: “It appears that inhibitory and stimulatory rTMS may well
prove useful tools in the long-term programs to rehabilitate stroke
patients” (European Journal of Neurology)
● However, this method still needs further refinement in application.
As there are cautions about stimulation of the wrong areas of the
brain that may result in unwanted results or undesirable effects on
the patient ☊

Figure 28. Ekso® Exoskeleton robotic device

10. Brain-computer interface or Closed Loop Brain

Stimulation
● Where a patient moves his paralyzed extremity through mind
control via a high-density EEG cap which transmits signals to a
computer, that controls specific muscles in that extremity.
● A promising technique for hemiparetic extremities
● Most critical part is connecting the machine into the peripheral
nerves to promote transmission of impulses.
● Further description of figure 29:(2021)
○ During the BMI therapy, the patient with upper-limb paralysis Figure 30. rTMS (Repetitive Transcranial Magnetic Stimulation)
would be asked to imagine/attempt to move his/her paralyzed
arm, and those intentions would be translated into the actual E. OTHER MODES OF MANAGEMENT
movement of the patient's limb. 1. Brain Imagery/Mental Imagery
○ The activity from the brain is recorded with noninvasive or ○ Mental Practice; this is a technique
invasive electrodes. Then, it is processed in a computer that ○ Modify motor performance
extracts relevant features and decodes information from the ■ Make use of of principles of neuroplasticity
imagined/attempted motor task, based on a calibration ○ CNS creating a template of movement without activating a
procedure performed with previously-recorded examples of motor plan
movement imaginations/attempts. ○ Activate descending corticospinal pathway, spinal cord and
○ The information decoded from the brain activity is translated effector muscles, without actually causing movement
into control commands for the robotic or prosthetic device, ○ Ex: surgeons visualizing operative procedure before doing the
which mobilizes the paralyzed limb of the patient, exciting actual surgery so that it will be somehow imprinted in their mind
his/her afferent pathways.
before they do the actual surgery ☊
2. Tai-Chi Exercises

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○ Slow movements emphasizing trunk and limb control

X. IMPORTANT POINTS
○ Also spiral and diagonal movements
■ Similar to Kabat’s PNF (proprioceptive neuromuscular ● Recovery in Stroke depends on:
facilitation techniques) ○ Location and extent of damage
○ For stroke patients and elderly with poor balance control ■ Most important factor
■ Preliminary studies have shown benefits for stroke ■ The bigger area of involvement, the poorer prognosis
rehabilitation ■ If the area affects the basic functioning of the brainstem, the
poorer the prognosis
3. Acupuncture
○ Activation of secondary areas
○ Variable results in improving movements
■ Like the secondary motor cortices
■ Some says it works to a certain extent, some says it does not
○ Activation of contralateral areas
work at all ☊
■ For example, right hand gripping action that triggers both
○ Should be utilized within 3 months post-stroke
hemispheric hyperactivity
○ Stroke is not a standard indication
● Interdisciplinary approach is the best due to complex problems
○ Pain control is the only indication for acupuncture
of the nervous system disorders
4. Communication Therapy ○ No single professional can handle all the complicated problems
○ By circumventing or deblocking the language deficit or helping in stroke patients
the patient to compensate for the lost ability to communicate. ☊ ○ Core members of the Stroke Rehabilitation Team
○ Use of word or phonemes retrieval and use of gestures. (Neurorehabilitation Medicine Team):
■ In early stage, there is a need to establish reliable means for ■ Physiatrist – Director/Coordinator
basic yes/no communication. ■ Neurologist/Neurosurgeon - as the case may be
○ Purpose: minimize isolation and encourage the patient to ■ Physical Therapist - very important; can start early on
actively participate in the management of his/her condition ■ Occupational Therapist - as the patient starts to recover
○ Remind caregivers and healthcare professionals to avoid ■ Speech and Language Pathologist - to establish early
simple, childish phrases or tasks. communication technique, so he can start participating in his
■ Patient may actually dislike it, or patient may learn or adopt own management
wrong way of communication ■ Psychologist
■ You want to prevent unwanted ability or ways of ■ Recreational or Vocational Therapists - especially if the
communicating ☊ patient is preparing to go home
■ Prosthetist-Orthotist- especially if the patient needs braces
F. FUTURE MODALITIES OF TREATMENT for the lower extremities
1. Stem Cells (in research) ■ Social Worker - especially when you are preparing the
○ First human stem cell-based study in humans with acute spinal patient to go home or for discharge
cord injury (SCI) using oligodendrocytes with progenitor cells. ■ Patient
○ Mesenchymal Stem Cells (MSC) ■ Others – family, caregivers, other therapists that may come
■ Bone marrow derived into the picture depending on the needs of the patient, etc.
■ For ischemic strokes ● For management:(2021)
■ Mechanism: ○ Early immediate intervention
● Activation of endogenous neuroprotective and ○ Task-specific activities along with the different management
neurorestorative pathways by the release of cytokines ○ Appropriate intensity (increasing intensity = more efficient)
and trophic factors, leading to increased neurogenesis, ● Improved upper extremity function may occur with subsequent
angiogenesis, and synaptic plasticity. vigorous and intensive therapy, strong motivation and good
cognition, provided that some selective hand movement is present.
2. Neuronal Growth Factors (2021)
○ Scientists are trying to discover new other neuronal growth
○ Finger movement must be seen in 3-4 weeks.
factors in addition to the neurotrophins, NGF and BDNF.
○ If no finger movements within that time, finger function will not
3. Gene Therapy
be complete.
○ Protection of neurons
○ Reduction of infarct size XI. CONCLUSIONS
○ Improvement of function ● Increase in neuronal plasticity after brain injury allows functional
4. Hi1a Factor recovery that can be seen from microscopic to macroscopic levels.
○ From Australian funnel-web spider venom ○ We’ve been able to show that especially with functional MRI,
○ Its venom can shut-off a pathway that triggers widespread near infrared spectroscopy, and we can even find the
death of cells after a stroke disruptions or activations of the nerve tracts through diffusion
○ Effective even after 8 hours post-stroke vs. 3-4 hrs. tensor imaging technique and some other newer techniques of
administration of rTPA. documenting the functional status of the CNS or brain.☊
○ Minimizes effects of brain damage after a stroke for the first 8 ● Recovery can be spontaneous (within a critical period of time) or
hours induced by training.
○ Neuroinflammation is decreased. ○ It can be expected, or can be induced further through
○ Being developed at the Univ. of Queensland/Monash University, rehabilitative training.☊
Australia ● Reorganization depends on the degree and type of injury.
5. To determine the most appropriate timing of modalities to optimize ● Synaptic, cytoarchitectural and neurogenesis changes constitute
neurorehabilitation interventions. the mechanisms of reorganizations.
● “Remodelling of brain maps” is therefore possible.
G. MANAGEMENT OF EARLY PHASE
○ It is possible in all age groups. ☊
● Start as soon as the stroke is complete and vital signs are stable ● Although the use of technology is exciting, it is still supportive in
● Usually within 48 hours nature to be therapeutic exercise which is high-intensity, repetitive
● Protocol for SSP (Stroke Society of the Philippines) and task-specific.

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c. Forced use of the normal limb

XII. CHALLENGES OF NEUROREHABILITATION
d. Mental Imagery
● Limit the severity of the initial injury to minimize loss of function. 7. FES stands for:
● To find and define major and minor neural pathways, and then, aim a. Functional electrical stimulation
to support neuroplasticity of compensatory neural circuits. b. Full electrical stimulation
● Find new approaches to care beyond task-oriented training. We c. Facilitatory electrical stimulation
need to utilize new technology to extend therapeutic techniques. d. F-wave mediated electrical stimulation
● Identify biomarkers in stroke recovery to predict outcome. 8. Transference principle of neuroplasticity means
● No two stroke patients are the same! (2021) a. Different forms of neuroplasticity occur at different times during
training
Challenges of Neurohabilitation vs. COVID-19
b. The experience must be relevant and have meaning
● Reduction in the number of beds dedicated for neurorehabilitation c. Neuroplasticity is more active in younger patients
● Shift of medical staff: physicians and nurses to COVID wards d. Neuroplasticity in response to one training experience can
● Limitation of home and outpatient rehabilitation services enhance acquisition of similar functional task performance
● In-patient rehabilitation limited to patients with severe post-acute 9. At present, this is the best way to facilitate motor recovery in
disabilities only. stroke patients
Telerehabilitation a. Positive reinforcement of the progress in rehabilitation
● The provision of rehabilitation medicine services (evaluation, b. Early initiation of facilitation exercise
management and patient education) to a patient over a distance. c. Use of neurotropic solutions
● A form of telemedicine that leverages telecommunication d. All of the above
technologies to deliver rehabilitation services synchronously or 10. The best time to start neurorehabilitation in stroke
asynchronously to remote patients, to minimize the barriers of patients
distance, time and costs. a. After about 1-week post ictus
○ When face-to-face rehabilitation is risky, impractical and costly. b. When the patient is awake and can fully follow
c. As soon as the patient is neurologically stable
XIII. REFERENCES d. As soon as there is motor recover from hemiplegia
Malaya, A. (2020) Neurorehabilitation. [PowerPoint Presentation and 11. A promising treatment modality that uses
recording] electromagnetic waves to enhance motor recovery
Batch 2021 Neurology II Transcription a. MRI
b. Functional MRI
REVIEW QUESTIONS
c. TMS - transcranial magnetic stimulation
2021 Feedback (same lecturer, #61-80) d. Transcranial Doppler stimulation
12. It refers to the process where treatment methods and
1. An example of a pharmacologic agent believed to enhance technology are utilized to maximize the efficiency of
neuroplasticity in stroke patients preserved neuromuscular structures in patient with motor
a. Cerebrolysin disability
b. Clopidogrel a. Neuroplasticity
c. Phenytoin (DILANTIN) b. Neurorehabilitation
d. Vitamin B complex c. Handicapping
2. The basic principle governing neuroplasticity that states: d. Stroke recovery
brain changes that result from bad habits or maladaptive 13. A strategy to induce neuroplasticity where “a template
behaviors can interfere with learning new, good habits or of movement is created in the brain without activating the
behaviors motor plan”
a. "Learned non-used" a. Mirror therapy
b. Use-dependent Plasticity b. CIMT
c. Interference principle c. Mental imagery
d. Transference d. Visualization
3. The most basic rehabilitation management to promote 14. A physical activity stimulation that uses computer
neuroplasticity in the CNS: interface that involves real time simulation of the
a. Administration of neurotrophic chemicals environment, scenario, or activity
b. Keep the patient calm through sedatives a. Mirror therapy
c. The early initiation of purposeful activities or movements b. CIMT
d. Transcranial magnetic stimulation c. Mental imagery
4. All of the following are identified as neurotrophins in the CNS, d. Virtual reality computer games or activities
EXCEPT: 15. A process of CNS neuroplasticity where unused
a. BDNF (Brain-derived neurotrophic factor) synapses or neural connections are reestablished to achieve
b. NGF (Nerve growth factor) functional recovery
c. NT-3 to 6 (neurotrophins) a. Angiogenesis
d. Pituitary growth hormone b. Synaptogenesis
5. One of the well studied exercise regimens to induce plasticity c. Neurogenesis
is CIMT, it means d. Stem cell migration
a. Constraint-induced motor therapy 16. On the other hand, the process of gaining plasticity in
b. Constraint-induced movement therapy the CNS through formation of new blood vessels to perfuse
c. Constant-induced movement therapy the infarcted areas:
d. Centrally-induced motion therapy a. Angiogenesis
6. The main principle behind the technique of CIMT is: b. Neurogenesis
a. Learned non-use of the affected limb c. Stem cell migration
b. Forced use of the affected limb d. Synaptogenesis

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17. The chemical factor that triggers the answer to d. Rood’s technique
question no. 76 is known as: 5. At present, this is the best way to facilitate motor recovery in
a. Nerve growth factor stroke patients
b. Neurotrophin 3 a. Early initiation of facilitation exercises
c. Synapotogen b. Positive reinforcement of the progress in rehabilitation
d. Vascular endothelial growth factor c. Use of neurotropic solutions
18. The external device, mostly for the lower extremities, d. AOTA
consisting of motorized braces powered by battery packs, 6. The best time to start neurorehabilitation in stroke patients
which can assist patients to ambulate independently with or a. 1 week post ictus
without assistive devices b. As soon as the patient is neurologically stable
a. Body-weight supported harness system with robotics c. As soon as there is motor recovery from hemiplegia
b. Computerized gait trainer d. When the patient is awake and can follow
c. Computerized harness support system 7. A promising treatment modality that uses electromagnetic
d. Exoskeleton robotic devices waves to enhance motor recovery
19. Neural stem cells are believed to have originated from a. Functional MRI
the following areas and may migrate to peri infarct areas in b. MRI
stroke. EXCEPT: c. TMS- transcranial magnetic stimulation
a. Choroid plexus d. Transcranial Doppler stimulation
b. Hippocampus 8. It refers to the process where treatment methods and
c. Subventricular regions technology are utilized to maximize the efficiency of
d. Ventricular zones preserved neuromuscular structures in patients with motor
20. The therapeutic exercise wherein mirrors are used to disability
trick the paralyzed extremity to move through a reflection of a. Handicapping
the normal extremity movements. b. Neuroplasticity
a. Brunnstomm’s technique c. Neurorehabilitation
b. Constraint-induced movement therapy d. Stroke recovery
c. Mirror visual feedback therapy 9. A strategy to induce neuroplasticity where “a template of
d. Neurodevelopmental techniques movement is created in the CNS w/o activating the motor
plan”
Answers: (1) a, (2) c, (3) c, (4) d, (5) B, (6) b, (7) a, (8) d, (9) d, (10) c, (11) c, (12) b, (13) c, (14) d, a. CIMT
(15) b, (16) a, (17) d, (18) d, (19) b, (20) c
b. Mental imagery
2020 Feedback (same lecturer, lifted from Batch 2021 trans) c. Mirror therapy
d. Visualization
10. A gait retraining program where poor trunk control is
1. One of the well-studied regimens that induces neuroplasticity
substituted with a body weight supported harness system
is CIMT which means?
a. Computerized harness suspension system
a. Centrally-induced motion therapy
b. Conventional gait retraining therapy with canes and ankle-foot
b. Constant-induced movement therapy
orthosis
c. Constraint-induced motor therapy
c. Gait trainer
d. Constraint-induced movement therapy
d. Treadmill training with bodyweight-supported by harness
2. The main principle behind the technique of CIMT is?
11. The process of neuroplasticity where unused synapses
a. Forced use of the affected limb
or neural connections are reestablished to achieve function at
b. Forced use of the normal limb
recovery
c. Learned non-use of the affected limb
a. Angiogenesis
d. Mental imagery
b. Neurogenesis
3. Which exercises emphasize superficial cutaneous stimulation
c. Stem cell migration
such as stroking, vibrating motions that evoke voluntary
d. Synaptogenesis
muscle activation?
12. The process of gaining plasticity in the CNS through
a. Bobath technique
the formation of the new blood vessels to perfuse the
b. Brunnstromm’s technique
infarcted area
c. Proprioceptive neuromuscular facilitation by kabat
a. Angiogenesis
d. Rood’s technique
b. Neurogenesis
4. The kind of exercise that uses quick stretching coupled with
c. Stem cell migration
manual resistance of affected limb in spiral and diagonal
d. Synaptogenesis
movement patterns
a. Bobath technique Answers: (1) d, (2) a, (3) d, (4) c, (5) d, (6) b, (7) c, (8) c, (9) b, (10) d, (11) d, (12) a
b. Brunnstromm’s technique
c. Proprioceptive neuromuscular facilitation by kabat

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SUMMARY
NEUROHABILITATION 5. Chemical mediators (Neurotrophins)
● A process whereby patients who suffer from impairment
following neurologic diseases, regain their former abilities, or if BRAIN RECOVERY
full recovery is not possible, achieve their optimal physical, ● The brain main either recover via spontaneous reorganization
mental, social and vocational capacity.” involving spared tissues and is time limited and/or training
● Prevention → Intervention → Rehabilitation induced recovery which is not limited by time and dependent
on patient’s rehabilitation
NEUROPLASTICITY
● Theory first proposed by psychologist William James (1890) NON-INVASIVE ASSESSMENT OF NEUROPLASTICITY
○ CNS capability to reorganize by forming new neural ● Strategies
connections throughout life ○ Functional MR
■ Studies dynamics of brain recognition after injury
BASIC PRINCIPLES OF NEUROPLASTICITY ○ Transcranial Magnetic Stimulation mapping
● There are ten principles, namely: ■ Determines electrical excitability of brain tissues
○ Use It or Lose It ○ Functional imaging (PETScan)
○ Use It and Improve It ■ w/ (11-C)-PK 11195, a benzodiazepine ligand, is a marker
○ Specificity for neuroinflammation
○ Repetition Matters ○ Single Photon Emission Computed Tomography (SPECT)
○ Intensity Matters ■ Detects neurotransmitters
○ Timing Matters ○ Diffusion Tensor Imaging (DTI)
○ Salience Matters ○ Regional Cerebral Blood Flow (rCBF) studies
○ Age Matters ○ Near infrared spectroscopy (NIRS)
○ Transference or Generalization ○ High Density Electroencephalogram(EEG)
○ Interference ○ Magnetoencephalography (MEG)
○ Scape (Swept Confocally-Aligned Planar Excitation)
WHY NEUROPLASTICITY IS POSSIBLE Microscopy
● The existence of significant diffuse and redundancy connectivity ○ Regional Metabolic Rate of Glucose(rCMRglc), by PET and
within the CNS SPECT
● Ability of new circuits to form through remapping
GOALS OF REHABILITATION
MECHANISMS FOR NEUROPLASTICITY ● Objectives for stroke rehab
● There are five mechanisms for neuroplasticity, namely: ○ Achieve a maximum level of functional independence
1. Angiogenesis ○ Minimize disability
2. Neurogenesis ○ Successfully reintegrate back into home, family and
3. Synaptogenesis community
4. Regeneration ○ Reestablish a meaningful and gratifying life

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