Indian Association of Physiotherapist

["[Downloaded from http:\/\/www.pjiap.org on Saturday, July 29, 2023, IP: 43.246.243.196] Reflections from Experts and personalized medical care can be given. The prevalence were asymptomatic. Cough was the most prevalent among all of Artificial Intelligence in healthcare has led to groundbreaking age groups, followed by sputum, and sore throat. Symptomatic results within a short period of time. India being a developing patients had a higher proportion of death and ICU admission, country has its own set of challenges in healthcare, especially 4.7% and 4.5% respectively. And headache was the most in Neurorehabilitation. India is on its way to becoming one common neurological symptom, followed by myalgia, anosmia the leading technology hubs and AI transformation levers is or ageusia. Severe neurological complications such as loss of playing a pivotal role in India\u2019s journey in providing efficient, consciousness, acute stroke and seizure were minimal, but accessible & affordable healthcare. Having faced dementia when happened, patients required supplementary oxygen firsthand at home, we are aware of some the challenges it therapy and intensive care unit admission. Once the patient brings and we started working on leveraging technology to solve is diagnosed with COVID 19, the patient is either admitted many of them. One of the leading causes of global disabilities or isolated according to the patient\u2019s symptoms. When is Neurological disorders, further it is the one of the top 10 life admitted, they are mainly treated at government designated impacting disorders. It\u2019s hard to provide proper Neurological COVID\u201119 hospitals, some patients are treated at 2ndary and care due to certain factors not limited to affordability but also tertiary\u2011level university hospitals.(Her, 2020) In South\u00a0Korea, conveyance problems around rural areas. Teleneurology since the number of confirmed patients has been small, and Teleneurorehabilitation have immense potential for general hospitals have not been directly affected by the chronic conditions related to caring people around the world. neurorehabilitation area. So far, in my personal experience, Teleneurorehabilitation can be approached differently in in\u2011hospital neurorehabilitation in general hospital level was high\u2011income and low\u2011income countries. We are envisioning a relatively unaffected by COVID\u201119, but local neurorehabilitation future wherein AI plays the pivotal role in shaping how Tele facilities faced many challenges. Rehabilitation centers and Neurorehabilitation is looked at. Neurological care should be long\u2011term care facilities make it vulnerable for infection. In accessible anywhere and by anyone. The use of AI would be case of South\u00a0Korea, long\u2011term care facilities are in charge revolutionary. Activities such Speech Recognition, especially of a considerable amount of subacute and subsequent Speech impairment can be detected through technology better neurorehabilitation for neurological disorders such as stroke, than humans as machines have the heads up over humans of traumatic brain injury, spinal cord injury and degenerative brain detecting infinitesimal changes changes. disorders. At the beginning of the corona outbreak last year, a cluster infection occurred in some long\u2011term care facilities. As Experience of covid 19 and a result, many hospitals and facilities have banned family visits Neurorehabilitation Symposium and have regulated hospital visits, allowing only one caregiver at a time. Also transfer between hospitals became difficult View Point from Korea due to strengthened quarantine guidelines. Also, in a study found that 32.3% of physical therapists reported depression Sung\u2011Bom Pyun and 18.5% of therapists showed anxiety symptoms due to the COVID\u201119 pandemic.(Yang, Kwak, Ko, & Chang, 2020) As Department of Rehabilitation Medicine, Korea University College of such, it has been shown that the ongoing COVID\u201119 situation Medicine, Seoul, South\u00a0Korea has increased psychological burden on neurorehabilitation From February 15, 2020, when statistics began to be collected, personnel as well. Total health care use has decreased as of July 21, 2021, there are a total of 182,265 confirmed slightly. According to the Korean Institute for Health and cases of coronavirus in South\u00a0Korea. As is well known, Social Affairs, outpatient decreased by 3.5% and admission South\u00a0Korea has been relatively successful in controlling the decreased by 12%. Also, most of the hospitals\u2019 health spread of corona infection with K\u2011Quarantine a0nd\u00a0the mortality insurance utilization decreased dramatically last year. The rate is as low as 1.12%. However, in the past two weeks, the decrease of patient number was most manifest in the pediatric number of confirmed cases has been rapidly increasing and it department. Thirty six percent less pediatric patients visited is approaching 2,000 confirmed cases per day. The distribution the hospital. In my experience, the number of outpatients also of confirmed cases is mainly concentrated in metropolitan decreased in the neurorehabilitation facilities, mainly pediatric areas such as Seoul, Incheon and Gyeonggi\u2011do. In addition, neurorehabilitation unit. Economic recession, unemployment confirmed cases are mainly caused by contact with other crisis has led to psychiatric disorders and these illnesses can confirmed cases, and the incidence in hospitals or nursing easily become chronic, harming public health so early diagnosis, facilities is very low at 0.5%. In South\u00a0Korea, the government prevention and consultations or treatments will be necessary. has strengthened the social distancing level, and the entire Also, Community social welfare facilities have reduced their metropolitan area is maintaining the strongest level\u00a0(level operations, and the number of facilities available to patients 4). In level 4, up to 4 people can dine together at an outdoor has been greatly reduced. In terms of the Neurorehabilitation restaurant, and only 2 persons can dine together after 6 pm. Society, the regular academic conference was not held last And the wearing of masks has continued to be compulsory year and the originally scheduled academic conference has nationwide, and benefits for those who have completed been reduced and held online. Also, there are many difficulties vaccinations have stopped. So far, 13% of the total population in holding events due to frequent changes of social distancing in Korea has been completed vaccination and 32% of total regulations, and the many society is running a deficit in terms of population have received the first dose of vaccination. In Korea, operation. South\u00a0Korea has a small land area and convenient the goal is to achieve a vaccination rate of 70% by November transportation, so almost of academic conferences were held of this year. In a study conducted in South\u00a0Korea,(Kim, Cho, face\u2011to\u2011face every week. However, due to COVID\u201119, online & Lee, 2021) it has been shown that 74.7% of patients had academic exchanges regardless of region have been quickly one or more symptoms on admission, while 25.3% of patients settled. And surprisingly, more people register and participate Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 15, Supplement 1, December 2021\t S153","[Downloaded from http:\/\/www.pjiap.org on Saturday, July 29, 2023, IP: 43.246.243.196] Reflections from Experts than in face\u2011to\u2011face academic events. And discussion on time many new DMTs have been introduced. The aim of a DMT non\u2011face\u2011to\u2011face neurorehabilitation has spread throughout is to arrest relapse and progressive disability and also to prevent the academic societies, medical organization and industry. MRI appearance of new lesion in the CNS. In other words, the The non\u2011face\u2011to\u2011face hospital visits to prevent the spread objective of DMT therapy is to achieve \u201cno evidence of disease of COVID\u201119 has proved its value in patients with chronic activity\u00a0(NEDA).\u201d The current thinking is to initiate DMT early in diseases. Currently in South\u00a0Korea, remote medical service or the course of illness to derive maximum benefit. Accordingly, telemedicine is not authorized, but active debate is going on the diagnostic criteria of RRMS has evolved over time to capture and it seems the advent will be introduced earlier. In summary, cases of MS early in the course of illness. At present the with COVID\u201119, neurorehabilitation is facing new demands. McDonald 2017 criteria for diagnosis of MS is followed, which is First, for the continuous rehabilitation of patients, the demand based upon clinical findings, MRI scan of CNS and presence of for home\u2011based or remote rehabilitation is increasing, such as oligo\u2011clonal band in cerebrospinal fluid\u00a0(CSF). DMTs are divided tele\u2011rehabilitation and digital health technology. Second, the into: First line drugs\u2011\u00a0those with moderate efficacy\u00a0(30\u201350% number of online\u2011based academic conferences and training reduction of annualised relapse rate) but with low risk of programs will increase even after COVID\u201119 pandemic is adverse effects. These include \u2011interferons, glatiramer acetate, over. Third, emphasis should be placed on the psychological teriflunomide, dimethyl fumarate and fingolimod. Second support of patients, families and caregivers, as well as health line drugs\u2011\u00a0 those of higher efficacy\u00a0 (reduction in annualised professionals of neurorehabilitation team. relapse rate\u00a0>\u00a050%) but at the same time with a higher risk of adverse effects. These include alemtuzumab, cladribine and \u200aReferences natalizumab. With alemtuzumab the complications include serious infections and appearance of autoimmune disorders. 1.\t Her M. How is COVID\u201119 affecting South\u00a0Korea? What is our Natalizumab, on the other hand, has the dynamic risk of current strategy? Disaster Med Public Health Prep 2020;14:684\u20116. developing progressive multifocal leukoencephalopathy\u00a0(PML). The dosages and routes of administration of the various 2.\t Kim HK, Cho YJ, Lee SY. Neurological manifestations in patients DMTs are as follows: Interferon\u2011beta 1b\u00a0(IFN\u00df\u20111b) 250 g\/500 with COVID\u201119: Experiences from the central infectious diseases g sc daily; interferon\u2011beta 1a\u00a0(IFN\u00df\u20111a) 22g\/44 g sc thrice a hospital in South\u00a0Korea. J\u00a0Clin Neurol 2021;17:435\u201142. week; interferon\u2011beta 1a\u00a0(IFN\u00df\u20111a) 30g IM weekly; pegylated IFN\u00df\u20111a 125\u00a0mcg sc every 2\u00a0weeks; glatiramer 20mg sc daily; 3.\t Yang S, Kwak SG, Ko EJ, Chang MC. The mental health burden teriflunomide 14mg orally daily; dimethyl fumarate 240\u00a0mg orally of the COVID\u201119 pandemic on physical therapists. Int J Environ twice daily; fingolimod 0.5\u00a0mg orally daily; natalizumab 300mg Res Public Health 2020;17:E3723. IV once every 4\u00a0weeks; alemtuzumab 12\u00a0mg\/day infusion for 5\u00a0days, then one year later 12\u00a0mg\/day for 3\u00a0days and cladribine Symposium on Multiple Sclerosis 2\u00a0 yearly treatment courses: 1.75\u00a0 mg\/kg\/course orally; each course divided into 2 treatment cycles; not to exceed 3.5\u00a0mg\/ Recent advances in medical management in kg cumulative dosage There are two schools of thought about MS how DMTs should be used in MS. In the \u201cInduction method\u201d, second line DMTs are used right at the beginning in order to Tapas Kumar Banerjee strongly prevent disability accrual. In contrast, in the \u201cEscalation method\u201d, first line DMTs are started at the beginning and if National Neurosciences Centre, Kolkata, West Bengal, India response is suboptimal then second line agent is considered. Multiple sclerosis\u00a0(MS) is a chronic, inflammatory, demyelinating Rules have been developed\u00a0(CANTOR, Rio and modified Rio) disease of the central nervous system\u00a0(CNS) affecting based upon clinical and radiological criteria to decide how to particularly the young adults. This disease is most prevalent in identify suboptimal response with a particular DMT and switch North America and Europe, less so in Asia and sub\u2011Saharan therapy. Certain drugs, which are currently \u2018off\u2011label\u2019 in the Africa. The clinical manifestation of acute attack depends upon Western countries, have also demonstrated benefit in modifying the site of demyelination. The site of demyelination could be the disease course of RRMS; these include azathioprine, optic nerve, spinal cord, cerebellum, brain\u2011stem or cerebral cyclophosphamide and rituximab. In recent times, newer hemisphere. According to the course of illness, MS subtypes DMTs are being introduced that are found efficacious in \u2018Active are Relapsing\u2011Remitting\u00a0(RRMS), Primary Progressive\u00a0(PPMS) progressive multiple sclerosis\u2019. Ocrelizumab in active primary and Secondary Progressive\u00a0(SPMS). PPMS accounts for progressive multiple sclerosis\u00a0(PPMS) and siponimod in active 10\u201115%, but the vast majority is RRMS\u00a0(80\u201185%). Over time secondary progressive multiple sclerosis\u00a0(SPMS) are found to RRMS might convert into Secondary Progressive MS\u00a0(SPMS). be of benefit in clinical trials. Incidentally, mitoxantrone also is Pharmacotherapy of multiple sclerosis can be divided into: 1. effective in SPMS at the dose of 12\u00a0mg\/m2\u00a0body surface area Treatment of acute attack 2. Disease\u2011modifying therapy\u00a0(DMT) IV every 3\u00a0months. But the maximum lifetime cumulative dose to arrest disease progression 3. Ancillary medications for should not exceed 72\u00a0mg\/m2 to avoid the risk of cardio\u2011toxicity. symptomatic relief Treatment of acute attack: RRMS is Ancillary medications for symptomatic relief: Patients with characterized by recurrent attacks with neurological deficit MS may have a wide range of symptoms like spasticity, lasting\u00a0>\u00a024 hours with intervening periods of remission. If urinary urgency, pain, depression, fatigue, etc., that require the acute event is moderate to severe, then to shorten attack symptomatic treatment. The medications used are as follows: duration high\u2011dose methylprednisolone therapy should be anti\u2011depressants for depression; amantadine or modafinil for considered, at a dose of 500\u20131,000\u00a0mg per day for 3\u20135\u00a0days. fatigue; baclofen, tizanidine, clonazepam, botulinum toxin for If the relapse is very severe and\/or not responding to pulse spasticity; oxybutynin, mirabegron or intra\u2011vesical botulinum methylprednisolone, plasma exchange is occasionally used. toxin for uninhibited bladder; tolterodine, solifenacin, external Disease\u2011modifying therapies\u00a0(DMTs): In 1993, the modern era of DMT in the treatment of RRMS began with the advent of subcutaneous injection of interferon beta\u20111b. Subsequently over S154\t Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 15, Supplement 1, December 2021","[Downloaded from http:\/\/www.pjiap.org on Saturday, July 29, 2023, IP: 43.246.243.196] Reflections from Experts sphincter injection with botulinum for detrusor\u2011sphincter bones. Both of these changes altered the action and behavior dyssynergia. Pregabalin, gabapentin or duloxetine is effective to of joint forces producing an inefficient movement and gait. control pain and paresthesia. For treatment of oscillopsia, drugs In Cerebral Palsy, lower limb levers at hip knee and ankle are like gabapentin, memantine, levetiracetam, clonazepam or altered. CP children\u2019s ability to walk progressively worsens over baclofen may be tried. Conclusion: There has been a paradigm time because of the resultant musculoskeletal impairments shift in the management of MS over the past three decades. caused by lever arm dysfunction. These changes often lead Previously, MS used to be generally perceived as an incurable to abnormal joint moments affecting the normal gait patterns disease with symptomatic medical therapy and rehabilitation depending upon the site of the lever arm dysfunction. the only options. With the advent of a wide range of DMTs, the While considering the management of musculo\u2011skeletal therapeutic dimension has now changed completely. In many deformity optimal treatment of the lever arm could significantly individuals the course of illness is now being arrested and the improve the quality of movement in children with CP. quality of life has improved manifold. We are optimistic that Types of lever arm disorders in CP with further developments of pharmacotherapies, one day MS 1.\t Short lever arm\u00a0(coxa valga) will be a curable disease. 2.\t Flexible lever arm\u00a0(pes valgus) 3.\t Mal\u2011rotated lever\u2011arm\u00a0(external tibial torsion) A systematic review on lever arm 4.\t Abnormal pivot\u00a0(hip subluxation or dislocation) dysfunction and surgical approach in 5.\t Positional lever\u2011\u00a0arm dysfunction\u00a0(crouch gait). Effect of Lever arm disorder in CP cerebral palsy gait 1.\t Change the line of muscle action, line of gravity and ground Taral V. Nagda reaction force resulting in abnormal internal and external joint moments Jupiter CP Clinic, Jupiter Gait Lab, SRCC NH Children Hospital, 2.\t Change in the mechanical advantage\u00a0(MA) of the body Mumbai, Maharashtra, India E\u2011mail:\[email protected] system. MA is based on the ratio obtained from internal The levers in human body system play an important role are and external moment arm that affects body joint and its determining the appropriate and efficient movement. In Cerebral function. Palsy, lower limb levers at hip knee and ankle are altered. Thus Lever arm dysfunction at ankle and foot: the gait of children with cerebral palsy is compromised in a variety Examples: Pes valgus, planovalgus, equinovalgus and tibial of ways. The normal moment of a joint complex is the product torsion of the muscle force and the lever arm. The neuropathology and Effects: Reduced planter flexion power. Ineffective ankle insult to brain in CP affects the growth plates in bones as well planterflexion knee extension couple as muscles and thus producing either the angular changes in Corrections: Orthosis. Surgery: calcaneal lengthening muscular force or the torsional changes at bones. The failure osteotomy, Foot stabilization. to produce an appropriate torque gives result from lever arm Lever arm Dysfunction at Knee: dysfunction and subsequent gait abnormalities. Recognition Examples: Crouch, fixed flexion deformity at knee and correction of lever arm disorders forms important aspect of Effects: Loss of mechanical effect to keep the ground reaction gait improvement in few children and adults with cerebral palsy. force in front of the knee joint. Increased demand on the Introduction quadriceps. Patella alta A lever is a rigid body rotating about an axis called the pivot. Correction: Orthosis, Hamstring lengthening\/transfer\/knee In a human body, bones could be considered as the rigid body flexion deformity with epiphysiodesis\/osteotomy, Patellar segments rotating around a joint as the pivot with forces created tendon advancement. by the adjoining muscles and ligaments. Lever arm dysfunction at Hip: Examples of levers in human body Examples: Hip rotation deformity, subluxation and dislocation The human body presents with all three kinds of levers, however Effects: The muscle imbalance at hip flexors\/extensor and class three is the most common. For a human body, the first class adductor\/abductor group. Effect on foot progression angle, of lever has fulcrum\u00a0(pivot) situated between the body segment Trendelenberg gait, Pain, deformity and reduced movements weight\u00a0(resistance) and muscular force\u00a0(e.g.\u00a0movement around Correction: Femoral osteotomy, Acetabular procedures, Hip the atlanto\u2011occipital joint). The second class of lever could be open reduction and reconstruction. seen as weight applied to toes where resistance falls between Conclusion the axis and force. There are many examples of third class of Children with CP show a variety of lever arm disorders with lever where this axis lies in between the resistance and the characteristics changes in gait pattern. The surgical approach force\u00a0(e.g.\u00a0knee joint movement). The levers in human body for gait correction vastly depends upon the gait and video system play an important role are determining the appropriate analysis. The importance of lever arm and their understanding and efficient movement. plays an important role in surgical corrections of joint structure Why are levers important in cerebral palsy and function. Various surgical approaches have been used for Lever arm dysfunction in children with cerebral palsy refers to correction of ankle, knee and hip lever arm dysfunction. The abnormal joint moment due to abnormal skeletal development. choice of the surgery and its outcome is suited best with kinetics The neuropathology and insult to brain in CP affects the growth and kinematics analysis of gait. plates in bones as well as muscles and thus producing either the angular changes in muscular force or the torsional changes at Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 15, Supplement 1, December 2021\t S155","[Downloaded from http:\/\/www.pjiap.org on Saturday, July 29, 2023, IP: 43.246.243.196] Reflections from Experts \u200aReferences and Further Reading 21.\t Krebs A, Strobl WM, Grill F. Neurogenic hip dislocation in cerebral palsy: Quality of life and results after hip reconstruction. 1.\t Rodda JM, Graham HK, Nattrass GR, Galea MP, Baker R, Wolfe R. J\u00a0Child Orthop 2008;2:125\u201131. Correction of severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic surgery. J\u00a0Bone Joint Surg Am 22.\t Heimkes B, Stotz S, Heid T. Pathogenesis and prevention of spastic 2006;88:2653\u201164. hip dislocation. Z\u00a0Orthop Ihre Grenzgeb 1992;130:413\u20118. 2.\t Theologis T. Lever arm dysfunction in cerebral palsy gait. J\u00a0Child 23.\t Pirpiris M, Trivett A, Baker R, Rodda J, Nattrass GR, Graham HK. Orthop 2013;7:379\u201182. Femoral derotation osteotomy in spastic diplegia. J\u00a0Bone Joint Surg Br 2003;85:265\u201172. 3.\t Kalkman BM, Bar\u2011On L, Cenni F, Maganaris CN, Bass A, Holmes G, et\u00a0al. Achilles tendon moment arm length is smaller in children 24.\t Root L. Surgical treatment for hip pain in the adult cerebral palsy with cerebral palsy than in typically developing children. patient. Dev Med Child Neurol 2009;51\u00a0Suppl\u00a04:84\u201191. J\u00a0Biomech 2017;56:48\u201154. Challenges of neurorehabilitation during 4.\t \u00d5unpuu S, Solomito M, Bell K, Pierz K. Long\u2011term outcomes of COVID19 surges in Bangladesh external femoral derotation osteotomies in children with cerebral palsy. Gait Posture 2017;56:82\u20118. Taslim Uddin, Moshiur Rahman Khasru 5.\t Kim HY, Cha YH, Chun YS, Shin HS. Correlation of the torsion Department of Physical Medicine and Rehabilitation, Bangabandhu values measured by rotational profile, kinematics, and CT study Sheikh Mujib Medical University, Dhaka, Bangladesh in CP patients. Gait Posture 2017;57:241\u20115. E\u2011mail:\[email protected] Background and Introduction: COVID\u201119 pandemic 6.\t Saglam Y, Ekin Akalan N, Temelli Y, Kuchimov S. Femoral distressed the health system globally. Existing burden of derotation osteotomy with multi\u2011level soft tissue procedures in neurological diseases is further intensified with COVID\u201119 children with cerebral palsy: Does it improve gait quality? J Child surges and this burden is profound in developing countries Orthop 2016;10:41\u20118. which may be different from country to country. Objectives: Objectives of this narrative review were to present 7.\t Kadhim M, Miller F. Crouch gait changes after planovalgus foot the COVID\u201119 and its surge impact on health and rehabilitation deformity correction in ambulatory children with cerebral palsy. system in Bangladesh. It was also directed to find out the Gait Posture 2014;39:793\u20118. challenges of neurorehabilitation services at this developing country. 8.\t Kadhim M, Holmes L Jr., Miller F. Long\u2011term outcome of Methods: This was a review study using an exploratory planovalgus foot surgical correction in children with cerebral nonsystematic method of PRISMA statements. This was further palsy. J\u00a0Foot Ankle Surg 2013;52:697\u2011703. strengthened with electronic literatures search using Pub\u2011Med, Google Scholar and Banglajol with the key words \u201dCOVID\u201119\u201d, 9.\t Kim HT, Jang JH, Ahn JM, Lee JS, Kang DJ. Early results of \u201cCOVID\u201119 surge\u201d, \u201cCorona virus disease\u201d, \u201cNeurological one\u2011stage correction for hip instability in cerebral palsy. Clin complications\u201d, and \u201cNeurorehabilitation\u201d. The literatures were Orthop Surg 2012;4:139\u201148. selected according to specific criteria relevant to Bangladesh as a developing country. Selected and retrieved data then 10.\t Ganjwala D. Multilevel orthopedic surgery for crouch gait in reviewed, analyzed and presented. cerebral palsy: An evaluation using functional mobility and Results: In Bangladesh the COVID\u201119 infection and death is at energy cost. Indian J Orthop 2011;45:314\u20119. peak, as reported on first week of July 2021 there were 930,042 total cases detected with more thant 15000 deaths exceeding 11.\t Foroohar A, McCarthy JJ, Yucha D, Clarke S, Brey J. Head\u2011shaft 150 daily deaths. It is the seventh most populous country in angle measurement in children with cerebral palsy. J\u00a0 Pediatr the world, and population of the country is expected to be Orthop 2009;29:248\u201150. nearly double by 2050. According to the WHO\u2019s Word Report on Disability, Bangladesh has more than 20 million people with 12.\t Rethlefsen SA, Healy BS, Wren TA, Skaggs DL, Kay RM. Causes disability which is further burdened with the noncummunicable of intoeing gait in children with cerebral palsy. J\u00a0Bone Joint Surg diseases\u00a0(NCD) related to rapid urbanization and the ageing Am 2006;88:2175\u201180. population. More, the country currently also hosts the largest refugee camp on the world. Its health system is poor, annual 13.\t Cobelji\u0107 G, Djori\u0107 I, Bajin Z, Despot B. Femoral derotation health budget is less than 1% of GDP. There were estimated osteotomy in cerebral palsy: Precise determination by tables. Clin 08 hospital beds, 5.6 doctors and 1.07 nurses per 10,000 Orthop Relat Res 2006;452:216\u201124. populations. It had serious shortage and mal\u2011distribution of health care workers making COVID\u201119 preparedness and 14.\t Kadhim M, Holmes L Jr., Church C, Henley J, Miller F. Pes mitigation difficult where neurorehabilitaion services remained planovalgus deformity surgical correction in ambulatory children challenging. Stroke, spinal cord injury, brain injury including with cerebral palsy. J\u00a0Child Orthop 2012;6:217\u201127. other neurological disorders registry is not maintained and rehabilitation team work is sidelined during COVID\u201119 surges. 15.\t Stefko RM, de Swart RJ, Dodgin DA, Wyatt MP, Kaufman KR, Majority of the rehabilitation centers across the country lacking Sutherland DH, et\u00a0al. Kinematic and kinetic analysis of distal rehabilitation professionals including occupational therapist, derotational osteotomy of the leg in children with cerebral palsy. speech language therapist, rehabilitation nurse, orthotist and J\u00a0Pediatr Orthop 1998;18:81\u20117. other essential rehabilitation team members. Physiatrists joined 16.\t Aiona M, Calligeros K, Pierce R. Coronal plane knee moments improve after correcting external tibial torsion in patients with cerebral palsy. Clin Orthop Relat Res 2012;470:1327\u201133. 17.\t Davids JR, Gibson TW, Pugh LI, Hardin JW. Proximal femoral geometry before and after varus rotational osteotomy in children with cerebral palsy and neuromuscular hip dysplasia. J\u00a0Pediatr Orthop 2013;33:182\u20119. 18.\t Rodda JM; Sciences H. Severe crouch gait in the sagittal gait patterns of spastic diplegic cerebral palsy: The impact of single event multilevel surgery. 2005. 19.\t Rozumalski A, Schwartz MH. Crouch gait patterns defined using k\u2011means cluster analysis are related to underlying clinical pathology. Gait Posture 2009;30:155\u201160. 20.\t Inan M, Altinta\u015f F, Duru I. The evaluation and management of rotational deformity in cerebral palsy. Acta Orthop Traumatol Turc 2009;43:106\u201112. S156\t Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 15, Supplement 1, December 2021","[Downloaded from http:\/\/www.pjiap.org on Saturday, July 29, 2023, IP: 43.246.243.196] Reflections from Experts the central pool of Covid 19 roster for triage and in association for short periods and training language was in english language; with the rehabilitation therapists they work to maintains an which was in appropriate and lead to misunderstanding. This online\u00a0\u2011\u00a0offline hybrid rehabilitation. Since March 2020 to April existing load was further burdened with an increased number 2021, about 3000 doctors and 2500 nurses of the country of neurological diseases were associated or presented as have been affected by the corona virus of which about 150 a complication of Covid\u201119. In a retrospective cohort study, doctors died of COVID\u201119 including an Associate professor among 236\u2009379\u00a0patients diagnosed with COVID\u201119, the of Rehabilitation Medicine. There were only 18.3% doctors, estimated incidence of a neurological diagnosis in the following nurses and midwives have been trained on infection prevention 6\u00a0months was 33\u00b762%. They have reported 14 neurological and control\u00a0(IPC) practices.\u00a0Manpower, fund placements, disorders including stroke, GBS, isolated nerve palsies in an space crisis for expansion and adaptation of rehabilitation increased incidence with heightened severity.\u00a0(Taquet M et\u00a0al. services were the major challenges to continue rehabilitation May 2021). services. Other issues included poor awareness about the Among the chronic neurological patients, there was a greater timely referral to the rehabilitation services and poor inter challenge in the supply of drugs, continuation of physical professional relationship about rehabilitation team functioning therapy and occupational therapy sessions for patients with among neurologists and the rehabilitation physicians. stroke, spinal cord injury, brain injury and other chroninc Discussion: Like many other parts of the world, musculoskeletal disabilities.\u00a0(Uddin T et\u00a0al. 2020). Home\u2011care is neurorehabilitation services in Bangladesh were severely especially important in these situations where telemedicine and affected by Covid 19 pandemic. This was mainly due to telehealth technologies are especially effective during epidemic countrywide lockdown restrictions, fear of getting corona surges. One recent international study stated more than 50% infections and squeezed opportunities of neurorehabilitation of the rehabilitation centers were providing telerehabilitation for services. According to the WHO, NCD kill 41 million people neurological disorders during the Covid 19 pandemic.\u00a0(Surya N each year globally and more than 85% of these deaths occur et\u00a0al. 2021) While waiting for full vaccine coverage or expected in low\u2011\u00a0and middle\u2011income countries. The health system of herd immunity, online and offline hybrid type of consultation Bangladesh is poor, experiencing a double burden of diseases, and continuation rehabilitation therapy services to maintain gait low service coverage and lack of an effective financial coverage training, spasticity specific therapy and preventive measures mechanism. for pressure injury are recommended. Characteristics of Bangladesh lags behind its neighbors in heath sector. About telerehabilitation for neurological disorders included patient two\u2011third of the total health expenditure is from out\u2011of\u2011pocket screening, monitoring disease status, to detect early signs of which 65% is spent to buy the medications. According to the of deterioration and provide prompt treatment, provision of WHO the doctor\u2011patient ratio in Bangladesh is at the second rehabilitation medicine consultation and planning therapy position from the bottom, among the South Asian countries. modalities, with real\u2011time assessment of clinical status.\u00a0(Smyth (Alam A, 2019.) A severe gap exists between the sanctioned C et\u00a0al. 2020). and filled health worker positions: 36% vacancy in sanctioned Conclusion: COVID\u201119 added neurological disease burdens on health worker positions and only 32% of facilities have 75% or the existing loads in the developing country. Telerehabilitation more of the sanctioned staff working in the facilities.\u00a0(WB 2009). has the potential to improve health outcomes, increase access Disability registration process is faulty where doctors and to health care, and reduce healthcare costs. Neurorehabilitation social workers who register people with disabilities are not require time demanded strategic planning for adjustment of the trained enough to distinguish between five types of neurological team works with required fund placements and recruiting more development disorders which require specialized knowledge rehabilitation workers. on disability.\u00a0(The Daily Star\u2011February 2021). There were more than 268\u00a0000 outpatient visits and 36\u00a0000 References emergency visits during the year 2019\u20112020 to a neurology dedicated hospital with 450 beds, staffed by 67 academic 1.\t Alam A; 2019. Available from: \u200a\u00a0https:\/\/www.dhakatribune. and clinical physicians including 5 physiatrists as an com\/health\/2019\/07\/21\/patient\u2011doctors\u2011nurses\u2011ratio\u2011 evidence of challenge taken by the neurorehabilitation team bangladesh\u2011lags\u2011far\u2011behind\u2011its\u2011 neighbours. members.\u00a0(Shahi MS et\u00a0al. 2020). In another study, among the total neurological spectrum of disorders presented at 2.\t Hossain MA, et al; 2020. Available from: https:\/\/doi.org\/10.1371\/ neurological department of public hospitals, about 25% were journal.pone. 0239646. diagnosed as stroke cases.\u00a0(Uddin MS et\u00a0al., 2018). The attitude of majority of the people of Bangladesh was strong, 3.\t Hussain M, et al; April 2021. Available from: https:\/\/doi. they belief that COVID\u201119 is controllable and containable org\/10.1002\/hpm. 3154. infection despite of repeated surging.\u00a0(Hossain MA et\u00a0al. 2020). But there was an increased anxiety and fear among frontline 4.\t Shahi MS, et al; 2020. Available from: http:\/\/dx.doi.org\/10.1136\/ service providers because of the highest death rate of doctors practneurol\u20112020\u2011002547. that might impact provision of a quality service\u00a0(Hussain M et\u00a0al. April 2021). IPC is a practical and evidence\u2011based approach 5.\t Smyth C, et al; \u00a02020. Available from: https:\/\/practicalneurology. to prevent patients and health workers from being harmed by com\/articles\/2020\u2011june\/poststroke\u2011telerehabilitation. infectious diseases. To achieve quality health care delivery an effective IPC training is essential for all level health care workers 6.\t\u200aSurya N, et al; \u00a02021. 10.3389\/fneur. 2021.626399. https:\/\/pubmed. including the rehabilitation team members.\u00a0(WHO\u00a0\u2011March 2021. ncbi.nlm.nih.gov\/33643202\/. During the Covid 19 pandemic, health care workers were trained 7.\t\u200aTaquet M, et al; \u00a0May 2021. Available from: https:\/\/www. thelancet.com.Doi:\u00a0https:\/\/doi.org\/10.1016\/S2215\u20110366\u00a0(21) 00084\u20115\/journals\/lanpsy\/article\/PIIS2215\u20110366\u00a0 (21) 00084\u20115\/ fulltext). 8.\t The Daily Star; February 12, 2021 Editorial. Available from: https:\/\/www.thedailystar.net\/editorial\/news\/ proper\u2011data\u2011needed\u2011ensuring\u2011disability\u2011rights\u20112043353. 9.\t Uddin MS, et al;\u00a02018. Available form: https:\/\/doi. Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 15, Supplement 1, December 2021\t S157","[Downloaded from http:\/\/www.pjiap.org on Saturday, July 29, 2023, IP: 43.246.243.196] Reflections from Experts org\/10.1159\/000481812. position\u00a0\u2013\u00a0spasticity is dynamic tone, and changes with position 10.\t\u200aUddin T, et al;\u00a02021. Available from: https:\/\/doi.org\/10.3329\/ Active\u00a0\u2013\u00a0how much active range is available In spasticity there is increased tone with increased movement Passive\u00a0\u2013\u00a0check jbcps.v38i0.47345https:\/\/www.banglajol.info\/index.php\/ the range of motion, strength, tone, check if there is a catch JBCPS\/article\/view\/47345. Functional activities\u00a0\u2013\u00a0tasks which are limited by spasticity On 11.\t W H O ; M a r c h 2 0 2 1 . A v a i l a b l e f r o m : \u200a\u00a0 h t t p s : \/ \/ considerations regarding spasticity in children: Spasticity in www.who.int\/bangladesh\/news\/ children may change over time and can later alter biomechanical detail\/23\u201103\u20112021\u2011building\u2011bangladesh\u2011capacity\u2011on\u2011infection\u2011 properties of joints and muscles. Spasticity is a dynamic prevention\u2011and\u2011control. problem and needs dynamic solutions. Latest Spasticity studies consensus show significant decreases in the EMG representation Symposium on Cerebral Palsy of spasticity documented 3\u00a0weeks after botulinum toxin A treatment, significant decrease in viscoelastic aspects of Management of spasticity in cerebral palsy spasticity present at 8\u00a0weeks, and subsequent increases in dorsiflexion range documented at 12\u00a0weeks for the botulinum Teresita Joy P. Evangelista toxin A group and improvement was found in performance goals at 12\u00a0weeks and in maximum voluntary torque and gross Physiatrist, Manila, Philippines motor function at 24\u00a0weeks for the botulinum toxin A. What are Cerebral Palsy\u00a0(CP) is a neurological disorder due to the adverse or unwanted effects of botulinum treatment The non\u2011progressive brain injury that occurs while the child\u2019s brain most common are:\u00a0 \u2014 Excess weakness in injected target is under development. The most common signs are motor muscles \u2014 Local bruising or pain at injection site \u2014 Diffusion impairments, causing developmental delays, and affecting of toxin to neighboring muscles \u2014 General fatigue, Short\u2011lived posture, walking and coordination. A\u00a0very common manifestation mild \u201cflu\u2011like\u201d symptom \u2014 Sensitization\u00a0\u2013\u00a0may occur infrequently is increase in tone or spasticity. The most well known and in 3 to 10% of cases What are contraindications to botulinum referenced definition of spasticity was proposed in 1980 by treatment \u00a0\u2014 Myasthenia gravis \u2014 Pregnancy \u2014 Should not Lance, as such: Spasticity is a motor disorder characterized be combined with neuromuscular junction drugs:\u00a0 \u2014 It may by a velocity dependent increase in muscle tone with interact with the aminiquinolones, cyclosporine In the 4 exaggerated tendon jerks, resulting from hyperexcitability of quadrants of management of spasticity in CP. The upper 2 the stretch reflex, it is one of the components of the upper motor quadrants constitute the general treatments, including baclofen neuron syndrome. In 2005 a definition from Pandyan, further and selective dorsal rhizotomy, the lower quadrants are the included, the disordered sensorimotor control resulting from focal treatments\u00a0\u2013\u00a0botulinum and surgery. In all quadrants an UMN lesion, presenting as intermittent or sustained Physical Rehabilitation is recommended and should be part of involuntary activation of the muscle. 90% of children with the management What are the advantages of Botulinum Cerebral Palsy have spasticity. This increase in tone, are most treatment in Spasticity \u2022 Effective in otherwise resistant manifest in the following muscles: shoulder adductors, elbow spasticity \u2022 Local effect, with little or no systemic action \u2022 Effects wrist and finger flexors, forearm pronators, and in the lower are titratable \u2022 May be improved with other treatments \u2022 extremities, most prominent in the hip adductors, knee flexors Injections should be repeated, as needed \u2022 Side effects, and extensors, and plantarflexors and invertors of the ankle. typically local to the injection site and are reversible What are Why do we need to treat spasticity in children Spasticity the limitations of Botulinum in the treatment of Spasticity \u2022 Not interferes with function and the child\u2019s development. Treatment indicated for treating generalized spasticity \u2022 Compared to oral of spasticity augments our other treatments. We want to avoid medications there is additional time needed for careful clinical permanent deformities, disabilities and surgeries. Spasticity evaluation and completion of the injection session \u2022 Repeated causes discomfort and even pain when the spastic muscle is injections are usually required to maintain and add to clinical stretched and spasticity interferes with caring of these children. results What is part of comprehensive management of Just as a review of Botulinum toxin: It is a toxin produced by Spasticity We should be able to match the following: 1. parent Clostriduum botulinum\u00a0\u2013\u00a0a gram positive anaerobic bacteria. and caregiver objectives 2. technical and functional objectives There are 7 serotypes of botulinum, of which A and B are 3. elimination of noxious stimuli 4. medications\u00a0\u2013\u00a0botulinum, commercially available as treatment for spasticity. The oral 5. surgery What are the management strategies for botulinum is prepared and diluted with other proteins, which Children with Spasticity Botulinum should ALWAYS be protects the toxin from hostile environments. Botulinum acts combined with other treatments, which includes Strengthening by binding presynaptically to high affinity recognition sites on of the muscles Stretching of the injected muscles Orthoses and the nerve terminals through the heavy chain, and the light chain other aids Functional training Who are the favorable candidates part cleaves the protein SNAP 25, a SNARE protein, a for Botulinum Patient Selection FAVORABLE Factors Focal presynaptic protein, which acts to allow fusion of vesicles with goals with specific anticipated functional benefits Dynamic acetylcholine. With botulinum there is disruption of endocytosis. muscle stiffness Good Head, Fair Trunk and Pelvic Control The end result is a failure of transmission across the UNFAVORABLE Factors Fixed contractures Deformities and neuromuscular junction. Recovery occurs through proximal joint instability Other medical conditions The Common Gait axonal sprouting and muscle reinnervation by formation of new Patterns in children with CP include\u00a0\u2013\u00a0from drop foot, equinus neuromuscular junction. Other studies suggest that eventually with different knee positions, and most common is still spastic the original neuromuscular junction regenerates. In the diplegia, presenting as true equinus to jump to apparent equinus management of Spasticity in CP children, these are the most and crouch How do we assess a CP child before injection \u2022 Do common questions that need to be clarified. How do we know a thorough physical examination \u2022 Dystonia screening \u2022 Do an if this is spasticity and not any other tone disorders Systematic evaluation of the degree of spasticity \u2022 Do functional and Practical approach to clinical assessment of spasticit Observe\u00a0\u2011\u00a0limb posture and how they change with S158\t Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 15, Supplement 1, December 2021","[Downloaded from http:\/\/www.pjiap.org on Saturday, July 29, 2023, IP: 43.246.243.196] Reflections from Experts assessments Modified Ashworth Scale is a quick and easy test, Authority\u00a0(MSMHA), Dementia DayCare, Smriti Vishvam: Universe developed in 1964 as a 5\u2011point scale and modified in 1987. of Memory, Mumbai, Maharashtra, India Interrater reliability improves with experience. The most ideal Caregiving is natural, inherent and involuntary. However, muscles to be injected with botulinum are those with grade of caregiving in dementia brings its own challenges. There is an 2. Modified Tardieu Scale is also used for assessment. It takes increase in ageing population and rising numbers of people into account resistance to passive movement at both slow and living with dementia all over the world with every 3\u00a0seconds fast speeds. The Goal Attainment Scale\u00a0(GAS) is also used. someone developing dementia\u00a0(World Alzheimer\u2019s Report, Two goals are set: one active, one passive and graded 2019) that has affected daily lives of families. The pandemic according to how important these goals are. The GAS is also has accentuated the problem and highlighted the role of a used to monitor response to treatment. The goals set in GAS caregiver even more. In fact, it has become a necessity to have may be changed depending on the status or progress of the a hired or an informal, family caregiver in dementia care. The child. What determines how much Botulinum is to be given to caregiver, whose personal watch on their wrist has stopped to the muscles Dose modifiers \u2014 Patient\u2019s body size and weight work, is actually an angel who is relentlessly working away \u2014 Degree of spasticity \u2014 Muscle mass and number targeted taking the entire onus of the person living with dementia on for injection \u2014 Concern of excess weakness \u2014 COST What their shoulder to becoming \u2018family\u2019 to the cared. What are is the importance of using Motor endplate\u00a0(MEP) targeted common challenges of caregivers It is observed that dementia injections The effect of the toxin relies on uptake at the motor robs individuals of their memory bringing a change of endplate\u00a0(MEP), the injection should be given as close as personality. Seen often are mood\u2011swings leading to difficult, possible into the motor endplates, to facilitate efficiency of irrational behavior, agitation and anger expressed through injections. Histological studies have been based on violent behavior, hitting, slapping, kicking, screaming, abusing cholinesterase staining of muscles. Inject areas with the largest and nasty by the person with dementia\u00a0(PwDem). Insomnia, concentration of MEPs. The degree of reduction of spasticity \u2018sundowning\u2019, hallucinations are other behaviors commonly induced by botulinum is proportional to the proximity of the seen. However common to both family\/informal carers and toxin to the MEP. In widespread distribution of MEPs, multiple professional carers, are problems of managing PwDem in injections are advised Other screening tools may include the performing activities of daily living. A\u00a0simple chore of brushing Hypertonia Assessment Scale, and the Barry Albright teeth or taking a bath is onerous as only cajoling with patience Dystonia\u00a0(BAD) scale to distinguish from dystonia. The Faces can work out for the caregiver. Handling activities in daily living Pain Scale for children is used to assess pain. The gait pattern is a task by itself. Dementia is a thief that steals the basic human charts are also used to record the type of gait. The most ideal dignity with flatulence, incontinence, loss of bladder control and candidates for spasticity management are those with true poor personal hygiene creeping in their daily lives. Later equinus gaits\u00a0\u2013\u00a0management of their spasticity can translate PwDem may have eating and swallowing difficulties or getting to improved gait Muskuloskeletal Ultrasound is now an choked often. Their frustration is reflected in their behavior important tool to assess depth of muscle and how deep our expressed by spitting, throwing food etc., Family caregivers injections must go. MSK UTZ helps us inject the correct muscles face other challenges of another kind. Most often they offer to and avoid nearby neurovascular structures. The motor end care out of guilt especially when the family member is not plates may also be localized using Electromyography, but the earning money for the home. They are taken for granted, use of the EMG has declined with the advent of the use of the derided and family who are not doing hands\u2011on caregiving UTZ in localizing muscles for injection. The EMG readings of interfering in their efforts. They have to provide round\u2011the\u2011clock spastic muscle include bursts of electrical activity on movement assistance to the family member which is difficult to do. They and at rest there may be continuous low\u2011level firing. Postural feel uncomfortable in asking for assistance or help to share stability measurements for CP using force plates and there are responsibilities. This often leads the individual to overlook their parameters are also used. A\u00a0stabilogram is generated to check own problems, be it health or their financial well being. Many on the displacement from the center of gravity. The child stands even avoid their own medical checks ups only to find out too on firm surface then foam surface. This can be used to monitor late that they have issues of comorbidity themselves. pre and post injection to check if stability has improved. Post Sometimes it is possible that they work on nervous energy only botulinum injection treatment is very important, as mentioned, to have a breakdown later. A\u00a0price they needlessly have to pay. botulinum needs to be combined with other treatments to be They have no time personal time to make themselves look successful, this includes serial casting, splinting, bracing, PT, good to feel good. Looking after a family member with dementia OT, stretching and strengthen and facilitate muscles, both often is a very sensitive problem. It is hard for them to see a injected muscles and antagonists. There is need to reassess sometime full of energy, hyperactive person, successful function and goals periodically with the medical and allied team professional or a homemaker who looked after the home and and the patient\u2019s family. family with love and pragmatism be stolen of their inner being. A\u00a0child may find the role reversal of caring much too stressful Symposium on Dementia and hard to handle. This is where other members in the family need to understand that they need to help too. A\u00a0professional Caregivers\u2019 perspective of challenges in caregiver has other challenges. Unacceptable behavior of dementia employers is the saddest and worst for caregivers to handle especially for those who come from rural areas or Vidya Shenoy below\u2011the\u2011poverty line communities who desperately need the job. Further, if things are misplaced families still suspect and Social Worker, Secretary General, Alzheimer\u2019s & Related Disorders accuse caregivers of theft or even crimes in spite of being Society of India\u00a0(ARDSI), Maharashtra State Mental Health aware that it is could have been done by the person living Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 15, Supplement 1, December 2021\t S159","[Downloaded from http:\/\/www.pjiap.org on Saturday, July 29, 2023, IP: 43.246.243.196] Reflections from Experts dementia. Added to this it is not uncommon that sexual be done by giving them respect, support and acknowledge their advances, groping or taking off clothes are done by the patient. efforts as often as one can. Remember they are doing what Problems of a caregiver can be broadly categorized as: they do because they have given up or made sacrifices to look Psychological: in the form of stress\u2011related frustration at work after someone they care about or need the job. They do deserve by not handling the person as nicely he or she has been doing much more than they give. Let us make them happy that they earlier or they could just be overburdened with their own enjoy the mission of caregiving! My deep gratitude to families personal problems they have no one to share with. Financial: with a member living with dementia, caregivers and most quite a few may have a family to support and take up these importantly my \u2018family\u2019 with dementia all over the world. For it services as they may be breadwinners for their homes or they is they who give me a glimpse into lives that have enriched me may be poorly paid for the services rendered. Physical: this job with their personal experiences. As a volunteer giving is thankless and exacting. Caregivers face exhaustion, have integrative therapies for the aging population and PwDem in hypertension, fatigue, aches and pains, loss of sleep, irregular our Dementia Daycare Centre, Smriti Vishvam; Universe of meal timings or experience of being overworked. Mental: it is Memory in Mumbai with ISO certification, in hospitals and very common for them to become sadists living a life with assisted\u2011living facilities it has been extremely rewarding an pessimism, depression, and in many case have suicidal experience. Over time, I have come to firmly believe that tendencies. Social isolation: this comes out of 365\u00a0days 24\u00a0\u00d7\u00a07 unconditional love, patience and Faith can work miracles in job with long hours of work with minimal social contact. peoples\u2019 lives and the therapists\u2019 lives too. Seeing qualitative Personal: sleep patterns and hours of sleep with meal times improvement in them, it is heartening to note that families being grossly affected. Their own future: lost opportunities of experience assuring comfort they are not alone in this journey. education, career, marriage and family life or employer support. Do keep in mind that every caregiving situation is unique and Most importantly, negligible self\u2011care, no medical checkups, there is no \u2018perfect caregiving\u2019 method to meet all the eating poorly, exercising less, skipping their own doctors\u2019 challenges. Most caregivers learn from trial and error in search appointments eventually can impact their health with a of the best way to care for their loved ones with a new purpose diminishing immune system, increasing risk of coronary heart to their lives. A\u00a0caregiver\u2019s role, though challenging, brings a disease, and\u00a0(for elderly caregivers) even increasing the risk sense of accomplishment and contentment to the self and hope of mortality. This means no \u2018me\u2011time\u2019. In all, a total burnout for to the cared. Knowing that eventually it is worth it after all by which, they need big help and support. How to try and meet being rewarded with a life\u2011\u00a0enriching, bonding experience. For these challenges faced by caregivers At ARDSI, we hold the caregiver and the cared have left indelible imprints in the caregivers support groups regularly. Often we need to remind hearts of each other. them that they must BEGIN WITH SELF\u2011CARE. To alleviate challenges of caregiving, we ask them to find the best way to \u200aReference try and prevent situations that arise often. If they have a difficult moment, we ask them to try and reduce the frustration that 1.\t Alzheimer\u2019s Disease International World Alzheimer\u2019s Report triggers their violent behavior. To be vigilant of family members 2019: Attitudes to Dementia. Available from: \u200a\u00a0https:\/\/www.alz. who may be causing the irritation. We tell them that a good co.uk\/research\/WorldAlzheimerReport2019.pdf. way is to create a better environment for them and communicate softly and slowly. Customized, flexible patient\u2011centric care with Rehabilitation management barrier lots of attention is very important. By keeping them busy with of stroke patients during pandemic: activities they have lesser time to feel neglected, lonely and isolated. It reassures that they are loved and needed by Indonesian experience everyone. COVID has made way for a pandemic with uncertainty of its stay. It has also has brought a new order in Vitriana Biben our lives with rigid restrictions. Therefore, situation now demands that whenever possible we share responsibility with Department of Physical Medicine and Rehabilitation, Dr.\u00a0Hasan families who have a member living with dementia, caregivers Sadikin General Hospital\/Faculty of Medicine, Universitas who need added community support, liberally use assistive Padjadjaran, Bandung, West Java Indonesia aids and technology for convenience and comfort of the PwDem Vitriana Biben Stroke is a disease with a prevalence of 10.9 and carer, regularly update medical records. help ensure legal per mil in Indonesia\u2019s population over the age of 15, or documents are in place, give caregivers their \u2018break\u2019 time, have estimated as much as 2.120.363 based on the result of The honest and healthy discussions with carers to give them Indonesian Basic Health Research\u00a0(Riset Kesehatan Dasar suggestions and learn from them too, listen to their challenges, Indonesia) conducted in 2018. This data shows an increase support them, if possible, wherever required and offer holistic from the same research results in 2013.[1] This disease is the rehabilitation, if and when necessary. Allow them access to third leading cause of death in Indonesia with a death rate of support groups, help them plan their future\u2011\u00a0 financial needs 138.268 deaths or 9.7% of total deaths,[2] but stroke as a that include life and medical insurance coverage and benefits. non\u2011contagious disease causes disability more often than We are interdependent on one another. As a society, we require death. Most post\u2011stroke patients experience disturbance in policy changes to ensure that caregivers do have a secure motor, sensory, balance, cognition, or other functions that can future after the person they cared for moves on or they hinder daily activities.[3] Obstacles in comprehensive stroke themselves age in the caring process and need help management in Indonesia are low awareness of stroke risk themselves. There is a NEED to take steps to re\u2011align lives of factors, unidentified stroke symptoms, non\u2011optimal stroke caregivers. As employers of caregivers they need to treat them management, lack of compliance towards therapeutic programs equally well to look after those living with dementia. This can to prevent recurrency of the stroke, and lack of understanding related to stroke rehabilitation. Those events could play a role S160\t Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 15, Supplement 1, December 2021","[Downloaded from http:\/\/www.pjiap.org on Saturday, July 29, 2023, IP: 43.246.243.196] Reflections from Experts in increasing new stroke incidents, a higher mortality rate due a new challenge for the rehabilitation team to overcoming of to stroke, stroke recurrency, and a higher disability rate in psychological issues beside the impact of stroke. To encounter Indonesia.[4] Stroke rehabilitation as a way to improve the quality the problems that caused by the pandemic, some policies of life in stroke patients has been executed comprehensively adopted by the hospital during the pandemic include in Indonesia since the patient is hospitalized\u00a0(acute phase) or encouraging the implementation of technology\u2011based in outpatient department\u00a0(sub\u2011acute and\/or chronic phase), but administrative systems that have been previously been initiated still lack of facilities to support the transitioning phase from in all hospital. In Rehabilitation Services, technology\u2011based hospital to home after the patient discharged from the hospital. rehabilitation\u00a0(telerehabilitation) to overcome all problems Currently, stroke rehabilitation services in most hospitals have related to the restricted face\u2011to\u2011face services due to the not been implemented ideally in Indonesia due to various things pandemic were encouraged. Several policies were reviewed such as lack of human resources, limited facilities and based on previous research to make realistic implementation infrastructures in the hospital. Related to the fulfillment of for Indonesia situation. Result of a research conducted in 2013 human resource needs, various efforts have been made such related to the identification of the need for an affordable as increasing the professional education program and technology\u2011based rehabilitation system for stroke patients in regulating the distribution arrangement in the context of equal Indonesia, showed5:\u00a0 1. Stroke sufferers need independent resources distribution by the government and all related exercise at home with flexible time and a therapy system that professional organizations. Currently, Indonesia has 909 is able to provide information about the exercise being carried physiatrists, 6.527 physiotherapists, approximately 2.000 out, provide feedback, give appreciation for the success of safe occupational therapists, 1.300 speech therapists and 400 exercise, and affordable costs 2. The size of the equipment orthotist prosthetists, who were not distributed evenly in all used should not be too large so that it can be used in the room Indonesia region. With Indonesia\u2019s population of 3. The exercises provided are related to daily activities and 271.349.889\u00a0(December 2020), this composition is not ideal in involve social interaction 4. Exercises are presented in an terms of the ratio of population and geographical situation of interesting and varied way 5. The exercise system allows user Indonesia which is an archipelago country. The Covid\u201119 to select exercises, save training data, and continuing exercises pandemic that occurred in 2020 has changed the process of that has been done before Currently, several Indonesian rehabilitation services. Recently, after going to normalization hospitals are using numerous alternative treatments that of rehabilitation services, the number of Covid cases in 2021 facilitates stroke sufferers by providing a telerehabilitation show tremendous increase again in Indonesia\u00a0[Figure\u00a01], after service integrated with hospital services, using various digital previously experiencing a drop in new cases in early 2021, so platforms and zoom meetings for teleconsultation with an it inflicting a big impact on stroke rehabilitation services in administrative record system that is integrated with hospital Indonesia. Figure\u00a01. Incidence of COVID\u201119 in Indonesia\u00a0(Source: services and insurance claims but the efforts to initiated https:\/\/covid19.go.id\/peta\u2011sebaran\u2011covid19) Rehabilitation telemedicine or telerehabilitation is not an easy step. Although services for stroke patients in hospitals during the pandemic the latest data shows that internet usage in Indonesia\u2019s in Indonesia then refer to the \u201cprotected code stroke\u201d, which is population is quite high\u00a0[Figure\u00a02], Indonesia faces challenges a form of additional protection so that stroke services can related to the uneven internet coverage in more remote areas continue to take place with both medical personnel and patients and uneven ability to fully utilize technology\u00a0[Figure\u00a03]. This safe from Covid\u201119 transmission. Several things were carried makes the approach of telemedicine must pay attention to this out to fulfill these principles depend on the ability of each condition Figure\u00a02. Data of internet user in Indonesia\u00a0(Source: hospital in Indonesia: 1. Cooperating with hospitals to design Ministry of Communications and Informatics Republic of service areas\u00a0(engineering system control) 2. Designing Indonesia\u2011https:\/\/kominfo.go.id\/content\/detail\/30653\/ telemedicine\u00a0\u2013\u00a0telerehabilitation by design 3. Availability of dirjen\u2011ppi\u2011survei\u2011penetrasi\u2011pengguna\u2011 internet\u2011di\u2011indonesia\u2011 good and appropriate PPE\u00a0(N\u201195 respirator or double mask) bagian\u2011penting\u2011dari\u2011transformasi\u2011 digital\/0\/berita_satker) for medical personnel 4. Prepare of disability vaccination plan Figure\u00a03. Internet distribution in Indonesia\u00a0(Source: Ministry of 5. Reducing the number of medical personnel during treatment Communications and Informatics Republic of Indonesia\u2011https:\/\/ and outpatient rooms by dividing the work schedule 6. Limiting aptika.kominfo.go.id\/2019\/08\/penggunaan\u2011internet\u2011di\u2011 the length of face\u2011to\u2011face consultations and prioritizing online indonesia\/) Profile of most internet users in Indonesia are young consultations in several hospitals 7. Limiting the variety of adults, with the dominant use of the internet is for social media, medical rehabilitation services 8. Limiting the number of patients so the stroke telerehabilitation approach should notice about visiting the polyclinic 9. Limiting the frequency of rehabilitation it, to make the approach more fit to stroke population program per week This strategy has led to a decrease in the character\u00a0[Figure\u00a02]. The technology of telerehabilitation make number of patients in both inpatient and outpatient at several rehabilitation services easier to afford for patients who need it Covid referral hospital centers because hospitals\u2019 health but the battered economy as a result of the pandemic, has services are currently focused on treating Covid\u201119\u00a0patients, caused additional money spending for internet quotas, and it in which continues to increase. The high number of became obstacle on the use of the technology. At the present Covid\u201119\u00a0patients today that come to hospital, make the time during pandemic of Covid\u201119, stroke rehabilitation services emergency room waiting time to be prolonged and it increased facing new challenges apart from having to look for alternative risk for a poor prognosis for stroke recovery, besides that, safe rehabilitation options during inpatient and outpatient several stroke patients were hospitalized Covid\u201119 infection. following WHO\u2019s guideline,[6] rehabilitation services are also Stroke patients who also suffer from Covid are undergoing facing a surge in post\u2011Covid patients who dominate several treatment in an isolated room, this then causes a sense of rehabilitation centers thus the focus arrangements and services trauma for the patient so they feel reluctant to return to the and medical personnel also require an adaptation in addition hospital to undergo an outpatient rehabilitation. This becomes to carrying out related rehabilitation. By looking at the data Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 15, Supplement 1, December 2021\t S161","[Downloaded from http:\/\/www.pjiap.org on Saturday, July 29, 2023, IP: 43.246.243.196] Reflections from Experts above, the option of telemedicine development for stroke as neglect and language abilities\u00a0(Lazar et\u00a0al. 2010, Marchi rehabilitation through telerehabilitation which packed in et\u00a0al. 2017). If this 70% proportional spontaneous recovery interesting way throughout social media are important to is a universal rule and cannot be influenced, this of course consider in a pandemic situation. Increasing interdisciplinary would mean that impairment oriented rehab is not possible. cooperation in this situation is very important and need to be The challenge is to change the slope\u00a0(i.e.from 70% to 80%or increased in a race against time to design alternatives usage more) or to make outliers inliers. Pharmacologically multimodal of technology accompanied by infrastructure and economic substances may be more effective in future compared analysis so that technological systems for rehabilitation services e.g.,\u00a0to antidepressants to facilitate post aczte recovery after remain affordable and can be applied in all of Indonesia area. stroke\u00a0(e.g.\u00a0Muresanu et\u00a0al. 2016, Bornstein et\u00a0al. 2018). In animal experimentation so called \u201eenriched environments\u201c \u200aReferences have been proven to facilitate brain repair. There has however been no translation from this experimental animal world to 1.\t Kementerian Kesehatan Republik Indonesia. Laporan Nasional the clinical bedside. Besides pharmacological treatments Riskesdas 2018. \u00a0Lembaga Badan Penelitian Dan Pengembangan possible additional candidates for a true \u201eimpairment\u201c oriented Kesehatan. treatment approach are neuromodulatory techniques such as peripheral neuromuscular and\/or sensory stimulation\u00a0(eg. 2.\t World Health Organization. WHO STEPS Stroke Manual: The whole hand subliminal \u201emesh\u2011glove\u201c stimulation) and more and WHO STEPwise Approach to Stroke Surveillance. \u00a0World Health more also non invasive brain stimulation techniques such as Organization; 2005. repetitive transcranial magnetic stimulation and transcranial DC stimulation. Also the use of non fatiguable robotic devices 3.\t Rafsten L, Meirelles C, Danielsson A, Sunnerhagen KS. Impaired to enable a high intensity massed movement treatment appear motor function in the affected arm predicts impaired postural promising. As treatment intensity is likely to be the key element balance after stroke: A\u00a0cross sectional study. Front Neurol for impairment reduction we certainly have to find clever and 2019;10:912. affordable ways: to increase the daily treatment time of our patients. To day even during inpatient rehabilitation treatment 4.\t Wardhana W. Strategi Mengatasi & Bangkit Dari Stroke. times hardly exceed three hours a day i.e.,\u00a0that we use only Yogyakarta: Pustaka Pelajar; 2011. a small percentage of waking hours leaving long \u201cidling\u201d time not field by any treatment. In this sense we have to \u201creinvent\u201d 5.\t Hariandja JR. Identifikasi Kebutuhan Akan Sistem Rehabilitasi neurorehabilitation within this sensitive post injury period to Berbasis Teknologi Terjangkau Untuk Penderita Stroke Di combat impairment with high frequency treatments combined Indonesia; 2013. Available from: \u200a\u00a0https:\/\/journal.unpar.ac.id. with neuromodulatory techniques\u00a0(robot use, peripheral and central stimulation, pharmaceuticals).A crucial role in the 6.\t World Health Organization. Mempertahankan Layanan implementation of high intensity treatment strategies is to Kesehatan Esensial: Panduan Operasional Untuk Konteks find ways to keep the patients\u00a0\u00d7\u00a0motivation up for long time COVID\u201119. \u00a02020. periods. Unfortunaely the pivotal role of motivation in the rehab treatment process has hardly ever been addressed in Impairment oriented rehab: The pivotal role detail. Here certainly further work is necessary to clarify the of intensity and motivation structure of intrinsic motivation in patients and also to find out if techniques as gaming, virtual\u2011\u00a0and\/or augmented reality may H. C. Volker H\u00f6mberg be helpful.Probably the most important impact in facilitating impairment reduction will however have clever, economically \u200aSRH\u2011\u00a0GBW Bad Wimpfen and Neurology Coordinator for the SRH feasible, approches to increase the net number of therapy or Hospital Group activity hours per day by creating true \u201e enriched environment\u201c Within the last 10\u00a0years the number of survivors after stroke for severely impaired patients. They should enable 6\u20118 hours and traumatic brain injury\u00a0(TBI) has dramatically increased of daytime treatment to avoid leaving our patients \u201einactive due to advances in acute medical care. Nevertheless the and alone\u201c in future. question remains if we have really made progress to influence impairment by restorative strategies rather than just improving References function and consecutively participation by compensatory strategies. This is more than just a \u201cphilosophical\u201d question 1.\t Muresanu DF, Heiss WD, Hoemberg V, Bajenaru O, Popescu CD, because the necessary strategies may be different, following Vester JC, et\u00a0al. Cerebrolysin and Recovery After Stroke\u00a0(CARS): different neurobiological and behavioural rules. We have been A\u00a0randomized, placebo\u2011controlled, double\u2011blind, multicenter very enthusiastic in successfully adopting elementary rules trial. Stroke 2016;47:151\u20119. derived from basic work on motor learning into motor rehab by optimizing trajectories in patients who have maintained 2.\t Bernhardt J, Dewey H, Thrift A, Donnan G. Inactive and alone: the ability to move at all\u00a0(at least a little bit), but we don\u00a0\u00d7\u00a0t Physical activity within the first 14\u00a0days of acute stroke unit care. really know if such \u201ctask\u2011specific\u201d motor learning is effective Stroke 2004;35:1005\u20119. in people who cannot move at all.Are we really able to influence impairment First published in 2008\u00a0 (Prabhakaran 3.\t Lazar RM, Minzer B, Antoniello D, Festa JR, Krakauer JW, et\u00a0al. 2008) described an interesting phenomenon: The Marshall RS. Improvement in aphasia scores after stroke is well spontaneous impairment recovery after stroke at day 90 after predicted by initial severity. Stroke 2010;41:1485\u20118. the ictus\u00a0(with or without treatment) for upper extremity was usually 70% oft he maximum possible difference between 4.\t Marchi NA, Ptak R, Di Pietro M, Schnider A, Guggisberg AG. initial score and the maximum possible. There were outliers Principles of proportional recovery after stroke generalize to from this rule attributable to severe pathology in the primary neglect and aphasia. Eur J Neurol 2017;24:1084\u20117. descending motor tracts especially the corticospinal tract. In the meantime this\u201cproportional recovery rule was also 5.\t Prabhakaran S, Zarahn E, Riley C, Speizer A, Chong JY, Lazar RM, demonstratesd to apply for impairments in non\u2011motor domains et\u00a0al. Inter\u2011individual variability in the capacity for motor recovery S162\t Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 15, Supplement 1, December 2021","[Downloaded from http:\/\/www.pjiap.org on Saturday, July 29, 2023, IP: 43.246.243.196] Reflections from Experts after ischemic stroke. Neurorehabil Neural Repair 2008;22:64\u201171. of and evidence for VR in stroke rehabilitation; and\u00a0(3) 6.\t Bornstein NM, Guekht A, Vester J, Heiss WD, Gusev E, H\u00f6mberg considerations for VR application in stroke rehabilitation. V, et\u00a0al. Safety and efficacy of Cerebrolysin in early post\u2011stroke Symposium on Telerehabilitation recovery: A\u00a0meta\u2011analysis of nine randomized clinical trials. Neurol Sci 2018;39:629\u201140. Digital evaluation of function in patients with brain disorder Central poststroke pain Won\u2011Seok Kim Witsanu Kumthornthip Associate Professor, Dept. of Rehabilitation Medicine, Seoul Department of Rehabilitation Medicine, Faculty of Medicine, Siriraj National University Bundang Hospital, Korea Hospital, Mahidol University, Bangkok, Thailand Functional evaluation is essential in neurorehabilitation to Pain is a common sequel of stroke including musculoskeletal monitor the patient\u2019s recovery and to make an individualized pain particularly shoulder pain, spasticity\u2011related pain, rehabilitation plan. Based on the concept of the International headache, complex regional pain syndrome, and other types Classification of Functioning\u00a0(ICF), patients with brain injury of chronic pain. Central poststroke pain\u00a0(CPSP) is a chronic have problems in multiple functional domains. For example, central neuropathic pain found in patients affected by stroke patients with stroke can have impairments in sensorimotor, with the prevalence up to 12% or more. It was formerly known cognitive, language, and visuoperceptual functions, which as thalamic pain syndrome described by D\u00e9jerine and Roussy leads to subsequent activity limitations and participation in 1906 manifesting as one of the most spectacular, distressing restrictions. Core measures in multiple domains are and intractable pain syndromes. It is characterized by persistent recommended\u00a0 (e.g.\u00a0 stroke severity: National Institute of or intermittent pain associated with sensory abnormalities Health Stroke Scale, Body function and structures: Fugl\u2011Meyer especially thermal sensation\u00a0(insensitive to heat and cold). Pain Assessment\u00a0(FMA), Activity limitations: Action Research Arm may be either spontaneous or stimulus\u2011evoked. It is frequently Test, 10m walk test, Quality of Life: EQ\u20115D, Global disability: described as burning, scalding, and freezing, while other modified Rankin scale).[1] These tests were usually performed symptoms include dysesthesia, allodynia, and hyperalgesia. and recorded by experienced experts in this field and the Its clinical manifestations are in the hemibody\u2011fashioned or manual tests still have their values, the digitization of this multifocal in the hemiplegic side. Clinically symptoms are information can open a new window to neurorehabilitation usually vague and hard to define, making an early diagnosis research. Automatic digitization of functional data can be difficult. It is sometimes misdiagnosed and delayed in diagnosis transmitted to and stored in an electronical medical record as a result of delayed development of clinical symptoms, database with less manual labors. Various sensors and robotic cognitive dysfunction and speech difficulty. The impact of CPSP devices give us the chance to automatically convert the motion on the patients with stroke includes psychological distress data to the functional scores in conventional measures and such as anxiety and depression, sleep disturbances, impaired to quantify the function that we can not usually measure activities of daily living and reduced well\u2011being and quality of life. manually such as movement quality or sensory function.[2,3] Management of CPSP includes pharmacological and The kinematic upper limb motion data during FMA can be non\u2011pharmacological treatment. CPSP is largely refractory to captured using sensors such as a depth\u2011sensing camera, medical and interventional treatments. Medications include inertial sensors, optic marker tracking, or data glove, and be tricyclic antidepressants, SNRIs, anticonvulsants, and further transformed to FMA scores.[4] Additional parameters opioids. Other treatment modalities are TENS, transcranial for movement quality can also be derived from this motion magnetic stimulation, motor cortex stimulation, deep brain data. Movement quality and kinematic assessments can stimulation, and psychotherapy. Outcomes are variable and be routinely performed in the standardized test condition need more evidence support and further studies to confirm the using appropriate sensors.[1,5] Combining wearable sensors effectiveness of treatment intervention. and Information and Communication Technology\u00a0(ICT), Details will be discussed in the presentation. teleassessment and continuous daily monitoring of patients\u2019 functions is possible.[6\u20118] In addition to traditional functional Robotics in Rehab evaluation, noninvasive brain monitoring with portable devices such as electroencephalography and functional near\u2011infrared Clinical application of virtual reality in spectroscopy provide the clinicians with chances to look into stroke rehabilitation the changes in brain function during the recovery process.[9,10] Therefore, the digitized data using various sensors in multiple Won\u2011Seok Kim functional domains during the long\u2011term recovery process can be cumulated more easily and used in the neurorehabilitation Associate Professor, Dept. of Rehabilitation Medicine, Seoul research to find out the new insights for recovery after brain National University Bundang Hospital, Korea injury, with also using up\u2011to\u2011date methodologies for big data Virtual reality\u00a0(VR) is a technology with a set of informatics that analysis such as some algorithms in artificial intelligence. New provides interactive environments to patients. VR can enhance parameters from digitized data can also be used to predict the neuroplasticity and recovery after a stroke by providing more recovery or to provide the optimal individualized rehabilitation intensive, repetitive, and engaging training due to several plan for the best recovery. advantages. My talk will cover:\u00a0(1) the technologies used in VR rehabilitation, including sensors;\u00a0(2) the clinical application Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 15, Supplement 1, December 2021\t S163","[Downloaded from http:\/\/www.pjiap.org on Saturday, July 29, 2023, IP: 43.246.243.196] Reflections from Experts References 6.\t Kim J, Sin M, Kim WS, Min YS, Kim W, Park D, et\u00a0al. Remote assessment of post\u2011stroke elbow function using 1.\t Kwakkel G, van Wegen EE, Burridge JH, Winstein CJ, van internet\u2011based telerobotics: A\u00a0proof\u2011of\u2011concept study. Front Dokkum LE, Alt Murphy M, et\u00a0al. Standardized measurement of Neurol 2020;11:583101. quality of upper limb movement after stroke: Consensus\u2011based core recommendations from the second stroke recovery 7.\t Lee JY, Kwon S, Kim WS, Hahn SJ, Park J, Paik NJ. Feasibility, and rehabilitation roundtable. Neurorehabil Neural Repair reliability, and validity of using accelerometers to measure 2019;33:951\u20118. physical activities of patients with stroke during inpatient rehabilitation. PLoS One 2018;13:e0209607. 2.\t Kim WS, Cho S, Ku J, Kim Y, Lee K, Hwang HJ, et\u00a0al. Clinical application of virtual reality for upper limb motor rehabilitation 8.\t Lum PS, Shu L, Bochniewicz EM, Tran T, Chang LC, Barth J, et\u00a0al. in stroke: Review of technologies and clinical evidence. J\u00a0Clin Improving accelerometry\u2011based measurement of functional use of Med 2020;9:3369. the upper extremity after stroke: Machine learning versus counts threshold method. Neurorehabil Neural Repair 2020;34:1078\u201187. 3.\t Porciuncula F, Roto AV, Kumar D, Davis I, Roy S, Walsh CJ, et\u00a0al. Wearable movement sensors for rehabilitation: A\u00a0focused review 9.\t Tedesco Triccas L, Meyer S, Mantini D, Camilleri K, Falzon O, of technological and clinical advances. PM R 2018;10:S220\u201132. Camilleri T, et\u00a0al. A\u00a0systematic review investigating the relationship of electroencephalography and magnetoencephalography 4.\t Kim WS, Cho S, Baek D, Bang H, Paik NJ. Upper extremity measurements with sensorimotor upper limb impairments after functional evaluation by fugl\u2011meyer assessment scoring using stroke. J\u00a0Neurosci Methods 2019;311:318\u201130. depth\u2011sensing camera in hemiplegic stroke patients. PLoS One 2016;11:e0158640. 10.\t Boyd LA, Hayward KS, Ward NS, Stinear CM, Rosso C, Fisher RJ, et\u00a0al. Biomarkers of stroke recovery: Consensus\u2011based 5.\t Schwarz A, Kanzler CM, Lambercy O, Luft AR, Veerbeek JM. core recommendations from the stroke recovery and rehabilitation Systematic review on kinematic assessments of upper limb roundtable. Neurorehabil Neural Repair 2017;31:864\u201176. movements after stroke. Stroke 2019;50:718\u201127. S164\t Physiotherapy - The Journal of Indian Association of Physiotherapists - Volume 15, Supplement 1, December 2021"]