The Clinical Science of Neurologic Rehabilitation (Contemporary Neurology Series, 66).pdf

The Clinical Science of

Neurologic Rehabilitation,

Second Edition

BRUCE H. DOBKIN, M.D.

OXFORD UNIVERSITY PRESS

Contents

Part I. Neuroscientific Foundations for Rehabilitation

1. ORGANIZATIONAL PLASTICITY IN SENSORIMOTOR AND

COGNITIVE NETWORKS 3

SENSORIMOTOR NETWORKS 4

Overview of Motor Control • Cortical Motor Networks • Somatosensory Cortical

Networks • Pyramidal Tract Projections • Subcortical Systems • Brain Stem

Pathways • Spinal Sensorimotor Activity

STUDIES OF REPRESENTATIONAL PLASTICITY 39

Motor Maps • Sensory Maps

BASIC MECHANISMS OF SYNAPTIC PLASTICITY 44

Hebbian Plasticity • Cortical Ensemble Activity • Long-Term Potentiation and

Depression • Molecular Mechanisms • Growth of Dendritic Spines • Neurotrophins •

Neuromodulators

COGNITIVE NETWORKS 52

Overview of the Organization of Cognition • Explicit and Implicit Memory Network •

Working Memory and Executive Function Network • Emotional Regulatory Network •

Spatial Awareness Network • Language Network

SUMMARY 64

2. BIOLOGIC ADAPTATIONS AND NEURAL REPAIR 76

TERMS FOR IMPROVEMENT AFTER INJURY 79

Compensation • Restitution and Substitution • Impairment and Disability

INTRINSIC BIOLOGIC ADAPTATIONS 81

Spontaneous Gains • Activity in Spared Pathways • Sensorimotor Representational

Plasticity • Spasticity and the Upper Motor Neuron Syndrome • Synaptogenesis •

Denervation Hypersensitivity • Axon Regeneration and Sprouting • Axon

Conduction • Growth Factors • Neurogenesis

POTENTIAL MANIPULATIONS FOR NEURAL REPAIR 99

Activity-Dependent Changes at Synapses • Stimulate Axonal Regeneration • Deploy

Neurotrophins • Cell Replacement • Pharmacologic Potentiation

MUSCLE PLASTICITY 113

Exercise • Atrophy • Regeneration • Combined Approaches

EXPERIMENTAL INTERVENTIONS FOR REPAIR OF SPINAL

CORD INJURY 118

Prevent Cell Death • Increase Axonal Regeneration • Remyelination • Other

Transplantation Strategies • Retraining the Spinal Motor Pools

Contents

RELEVANCE OF ANIMAL MODELS OF REPAIR TO

CLINICAL TRIALS 129

Eight Potential Pitfalls of Animal Models

SUMMARY 134

3. FUNCTIONAL NEUROIMAGING OF RECOVERY 147

NEUROIMAGING TECHNIQUES 148

Positron Emission Tomography • Single Photon Emission Computerized Tomography •

Functional Magnetic Resonance Imaging • Transcranial Magnetic Stimulation •

Magnetoencephalography • High Resolution Electroencephalography • Intrinsic

Optical Imaging Signals • Near-Infrared Spectroscopy • Magnetic Resonance

Spectroscopy • Transcranial Doppler • Combined Methods

LIMITATIONS OF FUNCTIONAL NEUROIMAGING STUDIES 160

General Limitations • Subtraction Studies • Timing of Studies

METABOLIC IMAGING AT REST AFTER INJURY 163

Stroke • Aphasia • Traumatic Brain Injury • Persistent Vegetative State

ACTIVATION STUDIES: FUNCTIONAL REORGANIZATION

AFTER INJURY 167

Sensorimotor Reorganization After Central Nervous System Lesion • Peripheral

Nerve Transection

TRAINING-INDUCED REORGANIZATION 176

Sensorimotor Training • Aphasia • Cognition • Cross-Modal Plasticity

NEUROPHARMACOLOGIC MODULATION 184

Monaminergic Agents • Other Agents

SUMMARY 185

4. NEUROSTIMULATORS AND NEUROPROSTHESES 193

PERIPHERAL NERVOUS SYSTEM DEVICES 194

Functional Neuromuscular Stimulation • Nerve Cuffs

CENTRAL NERVOUS SYSTEM DEVICES 198

Neuroaugmentation • Spinal Cord Stimulators • Brain–Machine Interfaces •

Sensory Prostheses

ROBOTIC AIDS 203

Upper Extremity • Lower Extremity

TELETHERAPY 206

SUMMARY 206

Part II. Common Practices Across Disorders

5. THE REHABILITATION TEAM 213

THE TEAM APPROACH 213

The Rehabilitation Milieu

Contents

PHYSICIANS 215

Responsibilities • Interventions

NURSES 218

Responsibilities • Interventions

PHYSICAL THERAPISTS 219

Responsibilities • Interventions for Skilled Action

OCCUPATIONAL THERAPISTS 231

Responsibilities • Interventions for Personal Independence

SPEECH AND LANGUAGE THERAPISTS 235

Responsibilities • Interventions for Dysarthria and Aphasia

NEUROPSYCHOLOGISTS 242

SOCIAL WORKERS 243

RECREATIONAL THERAPISTS 243

OTHER TEAM MEMBERS 244

SUMMARY 244

6. APPROACHES FOR WALKING 250

NORMAL GAIT 250

NEUROLOGIC GAIT DEVIATIONS 252

Hemiparetic Gait • Paraparetic Gait • Gait with Peripheral Neuropathy • Gait

with Poliomyelitis

QUANTITATIVE GAIT ANALYSIS 258

Temporal Measures • Kinematics • Electromyography • Kinetics • Energy

Expenditure

APPROACHES TO RETRAINING AMBULATION 262

Conventional Training • Task-Oriented Training • Assistive Devices

SUMMARY 268

7. ASSESSMENT AND OUTCOME MEASURES FOR

CLINICAL TRIALS 271

PRINCIPLES OF MEASUREMENT 272

Types of Measurements • Reliability and Validity • Choosing Measurement Tools

MEASURES OF IMPAIRMENT 275

Consciousness • Cognition • Speech and Language • Sensorimotor Impairment Scales

BEHAVIORAL MEASURES 288

Behavioral Modification • Neurobehavioral Scales

MEASURES OF DISABILITY 289

Activities of Daily Living • Instrumental Activities of Daily Living • Mixed

Functional Scales

xii

Contents

MEASURES OF HEALTH-RELATED QUALITY OF LIFE 298

Instruments • Adjustment Scales • Style Of Questions

MEASURES OF HANDICAP 302

MEASURES OF COST-EFFECTIVENESS 303

STUDY DESIGNS FOR REHABILITATION RESEARCH 303

Ethical Considerations • Types of Clinical Trials • Confounding Issues in Research

Designs • Statistical Analyses

SUMMARY 314

8. ACUTE AND CHRONIC MEDICAL MANAGEMENT 323

DEEP VEIN THROMBOSIS 323

Prevention

ORTHOSTATIC HYPOTENSION 324

THE NEUROGENIC BLADDER 325

Pathophysiology • Management

BOWEL DYSFUNCTION 329

Pathophysiology • Management

NUTRITION AND DYSPHAGIA 330

Pathophysiology • Assessment • Treatment

PRESSURE SORES 334

Pathophysiology • Management

PAIN 336

Acute Pain • Chronic Central Pain • Weakness-Associated Shoulder Pain • Neck,

Back, and Myofascial Pain

DISORDERS OF BONE METABOLISM 348

Heterotopic Ossification • Osteoporosis

SPASTICITY 348

Management

CONTRACTURES 357

MOOD DISORDERS 358

Posttraumatic Stress Disorder • Depression

SLEEP DISORDERS 363

SUMMARY 364

Part III. Rehabilitation of Specific Neurologic Disorders

9. STROKE 375

EPIDEMIOLOGY 375

Fiscal Impact • Stroke Syndromes

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